i-yy^T*Wf .'.'■•■•*V. ■ •.■,:'.:■ 'Lfc ,o ^:> K«v \ Y 02PARTME\TT. "i :?'A<:: ME0IC1NE& SURGERY. K/xiir ^ r* ' \: *:-' 1»V*J It I :, y;'# . «»/ .1Z1» V> > 4-' NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland LIB b. SECTION SHELF Work^Pthis Section cannot be taken from the Library except by written permission of the Bureau of Medicine and Surgery. *V 1 I ? , Philadelphia, October, 1871 LINDSAY & BLAKISTON'S New Medical Publications, AND NEW EDITIONS, ISSUED DURING THE PRESENT SEASON. "Trousseau s Clinical Medicine, Volume iv. FROM THE THIRD REVISED AND ENLARGED EDITION. Lectures on Clinical Medicine, delivered at the Hotel Dieu, Paris, by A. Trousseau, late Professor of Clinical Medicine, in the Faculty of Medi- cine, Paris, &c, &c. Vol. IV, Translated from the Third Revised and Enlarged Edition, by John Rose Cormack, M.D., under the auspices of the New Sydenham Society of London, and published in the United States by arrangement with them. Octavo, Cloth. Price, . . S4..00 CONTENTS OF VOLUME IV. Lkctukk 68, Dyspepsia; 69, Chronic Castritis; 70, Simple Chronic Uleer of the Stomach ; 71, Diarrhcpa, Chronic Diarrhrea; 72, Infantile Cholera, Diarrhoea of Chil- dren; 7'5, Lactation, First Dentition, and the Weaning of Infants; 74, Dysentery; 75, Constipation; 76, Fissure of the Anus; 77, Intestinal Occlusions; 78, Hepatic Colic, Biliary Calculus; 7!>, Hydatid Cysts of the Liver; 80, Malignant Jaundice; 81, Syphilis in Infants ; 82, (inut; 83, Nodular Rheumatism, erroneously called Rheu- matic (Jout; 84, Acute Articular Rheumatism, and Ulcerating Endocarditis. RECENTLY PUBLISHED. » Volume- I, II, and III of the same work, handsomely bound in cloth to match. Price, $5.00 each. Trousseau's Lectures on Clinical Medicine, so favorably received, as well by the profession of the United States as abroad, are published in this country in connection with the New Sydenham Society, under whose auspices the translation of Vols. II, III and IV have been made. Either volume can be furnished separate]v, and in order to still further extend the circulation of so valuable a work, the Publishers have reduced the price of the first three volumes to Five Dollars per volume, and will furnish Vol. IV at Four lhdlars. " Trousseau furnishes us with an example of the best kind of Clinical Teaching. It is a book that deserves to be popularized. The translation is perfect."— Medical Times and Gazette. " The great reputation of Prof. Trousseau as a practitioner and teacher of Medicine in all its branches, renders the present appearance of his Clinical Lectures particularly welcome."—Medical Press and Circular. " The publication of Trousseau's Lectures will furnish us with one of the very best practical treatises on disease as seen at the bedside."—British and Foreign Medico-Chirurgical Review. " A clever translation of Prof. Trousseau's admirable and exhaustive work, the best book of ref- erence upon the Practice of Medicine."—Indian Medical Gazette. " The Lectures of Trousseau, in attractiveness of manner and richness of thoroughly practical matter, worthily takes a place beside the classical lectures of Watson and Graves."—British Medical Journal. " Trousseau is essentially the French Graves, and his lectures should sooner than this have been translated into English."—Lancet. GrOWths in the La?ynX, Their History, Causes, Symptoms, Diagnosis, Pathology, Prognosis, and Treatment, with Reports and an Analysis of one hundred Consecutive Cases treated by the author, and a Tabular Statement of every published case treated since the invention of the Laryngoscope. By Morell Mackenzie, M.D., Physician to the Hospital for Diseases of the Throat, author of "The Laryngoscope," "Diseases of the Throat," &c. Profusely illustrated by 87 elegantly executed Wood Engravings, together with a number of Lithographic figures, and Chromo-Lithograph, or Colored, Illustrations, forming a handsome Octavo volume, printed on Cream Tinted Paper. Price, $3.00 " This book is undoubtedly the most complete and original essay on new formations in the Larynx which has appeared in this country. The author's comparisons of the merits of the operations, and the rules he lays down for the guidance of the practitioner, are by no means the least valuable por- ■ tion of a book, which we can cordially recommend to our readers."—Medical Times and Gazette. "The Use of the Laryngoscope in Diseases of the Throat, and Essays on Growths in the Larynx, are two monographs of first-rate merit. Dr. Mackenzie's Essays would do honor to any place; and he has used the opportunities afforded to diligence and skill to make solid and enduring con- tributions to science and practice. Both works are, throughout, models of honest and complete work, and are honorable to British medicine, as they are useful to practitioners of every country. The completeness of the clinical records, the abundant graphic illustrations, and the fulness of biblio- graphical references, are excellent features in both volumes."—British Medical Journal. BY SAME AUTHOR, SECOND EDITION. The Use of the Laryngoscope in Diseases of the Throat, With an appendix on Rhinoscopy, and an Essay on Hoarse- ness, and Loss of Voice, with additions, by J. Solis Cohen, M.D., Author of "Inhalation, Its Therapeutics and Practice," &c. Illustrated by two Lithographic Plates, and 51 Engravings on Wood. Price, . . $3.00 Acton s Functions and Disorders of the Reproductive Organs in Childhood, Youth, and Advanced Life. By William Acton, M.D. Third American from the Fifth London Edition. Octavo. Price,.............$3.00 "Mr. Acton has devoted himself for many years with unwearying assiduity to the study of the diseases of the reproductive organs, after an intimate acquaintance with syphilitic diseases gained in the Ciinique of M. Eicord; and we accordingly find that whether as regards the structure, the functions, or the diseases of the organs in question, every circumstance has received the minutest attention......."—Medical Times and Gazette. , " In the work now before us, all essential detail upon its subject-matter is clearly and scientifically given. We recommend it accordingly, as meeting a necessary requisition of the day."—The Lancet. " We think Mr. Acton has done good service to society by grappling manfully with sexual vice, and we trust that others whose position as men of science and teachers enable them to speak with authority will assist in combating and arresting the evil which it entails. We are of the opinion that the spirit which pervades it is one that does credit equally to the head and to the heart of the author."—The British and Foreign Medico-Chirurgical Review. Ganfs Science and Practice of Surgery, A Complete Text-Book including the Principles and Practice, by Frederick J. Gant, F.R.C.S., Surgeon to the Royal Free Hospital, London, &c, &c. With 471 Illustrations, and over 1100 Octavo pages. Price, . . 87.50 Dr. Gant's Surgery is similar in its general features to Dr. Errickson's excellent Text-Book on the Science and Practice, as comprising the whole of surgery, but it will have the great advantage of being an entirely new work, and appearing in a greatly condensed form, without the omission of any important subject. The matter through- out is fully brought up to the present time,—many original sources of information,. including the best treatises in Holmes:s System of Surgery, having been utilized, which have not heretofore been gathered into any general work on surgery, thus making it a more complete book for the student, and a work of ready reference for the practi- tioner. It is also illustrated by 471 new illustrations, which add much to its value. Pereira s Physicians' Prescription Book, THE FIFTEENTH EDITION. Containing Lists of Terms, Phrases, Contractions, and Abbreviations, used in Prescriptions, with Explanatory Notes, the Grammatical .Constructions of Prescriptions, Rules for the Pronunciation of Pharmaceutical Terms, A Prosodiacal Vocabulary of the Names of Drugs, &c.; and a series of Abbreviated Prescriptions illustrating the use of the preceding terms, &c; to which is added a Key, containing the Prescriptions in an unabbreviated form, with a Literal Translation, intended for the use of Medical and Pharmaceutical Students. By Jonathan Pereira, M.D., F.R.S., &c. Price, in Cloth, $1.25 ; in Tucks, with pocket, Si.50 " Although intended chiefly for the Medical practitioner and student, it will be found exceedingly convenient and useful for the Apothecary. There are many points of usefulness and interest in the book which claims for it a place in the Library of every pharmaceutical student."—American Journal of Pharmacy. Wythes's Physician s Pocket Dose and Symptom Book, THE TENTH EDITION, REVISED. Containing the Doses and Uses of all the Principal Articles of the Materia Medica, and Original Preparations ;'A Table of Weights and Measures, Rules to Proportion the Doses of Medicines, Common Abbreviations used in writing Prescriptions, Table of Poisons and Antidotes, Classification of the Materia Medica, Dietetic Preparations, Table of Symptomatology, Outlines of General Pathology and Therapeutics, &c. By Joseph H. Wythes, A.M., M.D., &c. Price, in cloth, $1.25; in tucks, $1.50 This little manual has been received with much favor, and a large number of copies sold. It was compiled for the assistance of students, and to furnish a vade-mecum for the general practitioner, which would save the trouble of reference to linger and more elaborate works. The present edition has undergone a careful revision. The thera- peutical arrangement of the "Materia Medica has been added to it, together with such other improvements as it was thought might prove of value to the work. Pulmonary Consumption ; Its Nature, Varieties, and Treatment. With an Analysis of One Thousand Cases to exemplify its duration. By C. J. B. Williams, M.D., F.R.S., Senior Consulting Physician to the Hospital for Consumption, and Charles Theodore Williams, M.D., Physician to the Hospital for Consumption, &c. Price, . . . S3.50 Prince s Plastic and Orthopedic Surgery, Containing Part I. A Report on the Condition of, and Advances made in, Plastic and Orthopedic Surgery, up to the Year 1871. Part II. A New Classification and Brief Exposition of Plastic Surgery. With numerous illustrations. Part III. Orthopedics: A Systematic Work upon the Prevention and Cure of Deformities. With numerous Illustrations. Octavo. Price, S4.50 Lindsay &? Blakiston s Physician s Visiting List for 1872. SIZES AND PRICE. For 25 Patients weekly. Tucks, pockets, and pencil, .... Si.00 50 " " " " ".....1.25 75 " " " " " ".....1.50 100 " " " " ".....2.00 if Ian- to June. ) 50 " " 2 vols., \ i , ^ y ".....2.50 5 ( July to Dec. j D 1 ( fan» to Tune. ) 100 " " 2 vols., < i , i. y ".....3.00 ' ( July to Dec. j ° The Interleaved Edition. For 25 Patients weekly, interleaved, tucks, pockets, &c, . . . $1.50 50 " " " •' " "... 1.75 1 ( lan- to Tune.) „ 50 " " 2 vols., < { , L, y " " ... 3.00 J [ July to Dec. j J Rihl <§>f G" Conner s Physician s Diary, Monthly, Semi- Annual, and Annual Journal and Cash-Book 'Combined. The Fourth Re- vised Edition. A large folio volume, with Printed Heads, Index, &c, &c. Bound in full leather. Price,............$7-5° Harris's Principles and Practice of Dentistry, THE TENTH REVISED EDITION. In great part rewritten, rearranged, and with many new Illustrations. Revised and edited by P. H. Austen, M.D., Professor of Dental Science and Mechanism in the Baltimore College of Dental Surgery, assisted by Prof. Gorgas and Thos. S. Latimer, M.D. With 400 Illustrations. Price, in Cloth, $6.50; in Leather, 7.50 Meadows''s Manual of Midwifery, a new text-book. Including the Signs and Symptoms of Pregnancy, Obstetric Operations, Diseases of the Puerperal State, &c, &c. By Alfred Meadows, M.D., Member of the Royal College of Physicians, &c, &c. First American from the Second London Edition, with numerous Illustrations. Price, . $3.00 Dillnberger s Handy-Book of the Treatment of Women and Children s Diseases, according to the Vienna Medical School. Translated from the Second German Edition, by P. Nicol, M.D. Price,............$1-75 Byford on the Uterus, second edition. On the Chronic Inflammation and Displacements of the Unimpregnated Uterus. By W. A. Byford, A.M., M.D., Professor of Obstetrics, and Diseases of Women, in Chicago Medical College ; and author of " The Practice of Medicine and Surgery, Applied to the Diseases of Women." A New, Enlarged, and thoroughly Revised Edition, with numerous Illus- trations. One volume, Octavo. P<-5™» ... S*.oo Tanner and Meadows's Practical Treatise on the Diseases of Infancy and Childhood, By Thomas Hawkes Tanner, M.D. The Third American from the last London Edition, by Alfred Meadows, M.D., author of "A Manual of Midwifery," &c, &c. One volume. Price,......$3-5° Tilt's Change of Life in Health and Disease, A Practical Treatise on the Nervous and other Affections incidental to Women at the Decline of Life. By Edward John Tilt, M.D. From the Third London Edition. In one volume Octavo. Price, . . $3.00 Duchenne s Localized Electrization, Translated from the Third Edition, by Herbert Tibbitts, M.D.,L.R.C.P. Lond., Medical Superintendent of the National Hospital for the Paralyzed and Epileptic. With 92 Illustrations, and Notes and Additions by the Translator. Price,...............S3.00 Upright on Headaches, a new edition. ' Their Causes and Their Cure. By Henry G. Wright, M.D., Member of the Royal College of Physicians, &c, &c. From the Fourth London Edition. Price,................$1.25 Reynolds's Lectures on the Clinical Uses of Elec- tricity, delivered at the University College Hospital, by J. Russell Reynolds, M.D., F.R.S., Professor of the Principles and Practice of Medicine, University College, London, editor of "A System of Medicine," &c, &c. One volume, Post Octavo. Price,.......$1.5° et's Surgical Pathology, third london edition. Lectures delivered at the Royal College of Surgeons of England, by James Paget, F.R.S., Surgeon to Bartholomew and Christ's Hospital, &c, &c. The Third London Edition, Edited and Revised by William Turner, M.B., Lond., Senior Demonstrator of Anatomy in the University of Edin- burgh, &c, cvc. In one volume, Royal Octavo. With numerous Illus- trations. Price,................$7-5° " It would be very superfluous for us to say many words in calling the attention of the profession to this n(p edition of Mr. Paget's great work on Surgical Pathology. Its author has been singularly fortunate in securing the assistance (for this edition) of so able a collaborator as Mr. Turner, and English surgery may point with pride to the present volume as one unsurpassed, if it is at all equalled in the surgical literature of the world, in breadth of view and philosophical grasp of its subject."—Practitioner. Beasley's Druggists' Receipt Book, seventh am. ed. Comprising a copious Veterinary Formulary, numerous Receipts of Patent and Proprietary Medicines, Druggists' Nostrums, &c.; Perfumery and Cosmetics, Beverages, Dietetic Articles and Condiments, Trade Chemicals, Scientific Processes, and an Appendix of Useful Tables, by Henry Beas- i.ey, author of the Book of Prescriptions, &c, &c. Price, . . . S3.50 Pag Rindfleisch's Text-Book of Pathological Histology. 208 Illustrations. An Introduction to the Study of Pathological Anatomy. By Dr. Edward Rindfleisch, 0. 0. Professor of Pathological Anatomy in Bonn. Translated from the Second German Edition, by Wm. C. Kloman, M. D., assisted by F. T. Miles, M. D., Professor of Anatomy, Uni- versity of Maryland, A:c, &c. CONTENTS. Introduction, Author's and Editor's Prefaces. General Part. 1. Decomposition and Degeneration of Tissues. 2. Pathological New Formations. Special Part. 1. Anomalies of the Blood and the Places 9. Anomalies of the Ovaries. of its Formation, especially of the 10. << " Testicles. Spleen i md Lymphatic Glands. 11. " " Mammas. 2. Anomalies of the Circulatory Appa- 12. " " Prostate Gland. ratus. 13. t< " Salivary Glands. 3. Anomalies of Serous Membranes. 14. " " Thyroid Gland. 4. " the Skin. 15. " " Suprarenal Cap- 5. " Mucous Membranes. sules. 6. (i the Lung. 16. (< " Osseous System. 7. << " Liver. 17. >i " Nervous System. 8. ti " Kidney. 18. k " Muscular System. Index and Bibliography. Containing 208 Elaborately Executed Microscopical Illustrations. One volume, octavo. Price, cloth, $6.00; sheep, $7.00. Prof. Rindfleisch's Text-Book of Pathological Histology, so justly celebrated in Germany, where it is considered the most complete and thorough work of its kind, having passed rapidly to a second edition, is also very highly valued and commended by German Medical scholars in this country, many of whom are not only familiar with the book, but with the author's great reputation as a teacher and professor of this branch of medical study. The translators are both gentlemen who by their past education have been peculiarly fitted for the task of translating the work. Dr. Kloman from early life has been familiar with the German language, while Prof. Miles has made the subject one of special study, both gentlemen being also praotical microscopists. The Publishers therefore offer a translation of this truly valuable work to the Medical Profession in the United States, feeling the utmost confidence that in both manner and style it will prove acceptable to them. In their Preface, the Translators say: "In presenting the English reading portion of the Medical Profession with %% translation of the valuable work of Prof. Rindfleisch, the translators scarcely deem an apology necessary. The merits of the book itself, and the fact that it fills an unoccupied gap in our most recent literature upon the subject of Pathological Histology, was judged to be an ample in- centive for undertaking the labor of the translation. The work of Virchow translated by Chance, is, in many points, antiquated, and the more recent work of Bilbroth, translated by Hackley, occupies the ground but partially, and is professedly a work of Surgical Pathology." This book is translated and published in this country by special arrangement with the author. Waring s Practical Therapeutics, a new edition. Considered chiefly with reference to Articles of the Materia Medica. By Edward John Waring, F.R.C.S., F.L.S., &c, &c. Second American, from the Third London Edition. Royal Octavo. Price in Cloth, 85.00; Leather, 6.00. There arc many features in Dr Waring's Therapeutics which render it especially valuable to the Practitioner and Student of Medicine, much important and reliable information being found in it not contained in similar works; it also differs from them in its completeness, the convenience of its arrangement, and the greater promi- nence given to the medicinal application of the various articles of the Materia Medica in the treatment of morbid conditions of the Human Body, &c. It is divided into two parts, the alphabetical arrangement being adopted throughout; there is also added an excellent Index of Dtskasks, with a list of the medicines applicable as remedies, and a full Index of the medicines nnd preparations noticed in the work. " This new edition of Waring's Practical Tlicrapcutics lias been altered and improved with great judgment. A satisfactory account of new agents—chloral, apomorphia, nitrous oxide, carbolic acid, &c, is introduced without adding to Its bulk. Theadditions arc made with remarkable skill in con- densation. It is one of the best manuals of therapeutics yet in existence."—Brit. Med. Journal. "There lias been no scarcity, latterly, of works of this class, several of them we regard as having great professional value ; but, it must, be allowed, wo think, that this holds no inferior place among them. StilliVsis a national book, but much more voluminous; and, therefore, while it is high author- ity, it is less convenient for office use. Furthermore, we prefer the literary arrangement and execu- tion of ll'nring. It can be used with more readiness and always relied on for tho correctness of its (acts. In the daily treatment of diseases, it seems to supply everything that can be desired. The articles are arranged alphabetically, and a paragraph is devoted to their physical description and scientific character. Their therapeutic uses, however, constitute the bulk of the volume; and in this respect the labor has been very thorough."—Druggists'1 Circular. "The plan of this work is admirable, and well calculated to meet the wants of the busy practi- tioner. There is a remarkablo amount of information, accompanied with judicious comments, im- parted in a concise yet agreeablo style. The indications for the application of remedies are sufficiently comprehensive, and their mode of action generally accounted for on rational grounds. The publishers have well performed their part, .and we trust that their enterprise in introducing the work to tho profefsi.xi in America may meet with that encouragement which tho inherent merits of the treatise itself aro entitled to command."—Medical Record. " Our admiration, not only for the immense industry of the author, but also of the great practical value of the volume, increases with every reading or consultation of it. We wish a copy could be put in the hands of every student or practitioner in the country. In our estimation it is the best book of the kind ever written."—A. 1'. Medical Journal. " It Is, Indeed, one of the most praetiea 1 works that has ever attracted our attention. Combining tho merits of Wood, Beck, Still;-, and the V. S. Dispensatory, it forms a volume which no young physician can afford to be without."—Chicago Medical Journal. "This work is a raonumont of industry and perseverance, invaluable both to tho Practitioner and Student."—Canada Medical Journal. "Mr. Waring has produced a volume which entitles him to the thanks of Students as well as of all who need a work on Therapeutics."—American Medical Journal. "A more laborious, painstaking, and valuable composition does not exist in any other language on tho subject; ono that should be in every practicing Physician and Surgeon's study, without which their libraries, no matter how rich otherwise in works on Materia Medica. must of necessity be incomplete."—Dublin Quarterly Journal of Medicine. " No work on this subject has appeared that can be more fully recommended to the Student and Physician. It not only contains all that is actually necessary to the Practitioner, but affords other- wise, much useful, valuable, and novel instruction. The oldest Physician and the most accurate Student will And iu it much that has not, and cannot be seen elsewhere. No one can consult its pages without receiving practical iuformation and judicious counsel."—Richmond Medical Journal. Popular Text-Books, Published by LINDSAY & BLAKISTON. CAZEACX*S Text-Book of Obstetrics.—Filth American Edition. Illustrated. WAKIW'S Practical Therapeutics.-From the Third London Kdition. RINDFLEISCH'S Text-Rook of Pathological Histology. -Illustrated. AITKEX'S Science and Practice of Medicine. ■-2 volumes. Illustrated. TANNER'S Practice of Medicine. -Fifth American from the Sixth London Edition. MEIGS «fe PEPPER'S Practical Treatise on the Diseases of Children—Fourth Ed. TANNER A MEADOWS Diseases of Infancy and Childhood.-Third American Ed. BIDDLE'S Materia Medica, for Students. Fomth Edition. With Illustrations. WANT'S Science and Practice of Surgery.-1711 illustrations. HARRIS'S Principles and Practice of Dentistry. -The Tenth Revised Kdition PAGET'S Surgical Pathology.—By Turner. Third London Edition SOELBERG n'ELLN on Diseases of the Eye. -Second London Edition. BYFORD'S Practice of Medicine and Surgery, applied to the Diseases of Women. —Second Edition. Illustrated. HEWITT'S Diagnosis and Treatment of the Diseases of Women. -Second Edition. HEADLAND on the Action of Medicines. -Sixth American Edition. BEAEE'S How to Work with the Microscope__Fourth Edition. KIRKE'S Handbook Oil Physiology .—The Seventh London Edition. MANUALS FOR STUDENTS. MEADOW'S Manual of Midwifery, Including the Signs and Symptoms of Pregnancy, Obstetric Operations, ire. From the Second London Edition. LAWSON'S Diseases and Injuries of the Eye, their Medical and Surgical Treatment. CHEW'S Lectures on Medical Education. MENDENHALL'S Medical Student's Vade Mecum—The Tenth Edition. 224Illustrations. ROBERTSON'S Manual for Extracting Teeth__Second Edition. Revised. DIXON'S Practical Study of the Diseases of the Eye__Third Edition. PEREIRA'S Physician's Prescription Book—The Fifteenth Revised Edition. REESE'S Analysis of Physiology. -Second Edition. WYTHES' Pocket Dose and Symptom Book. Tenth Edition, with Additions. BARTII <& ROGER'S Manual of Auscultation and Percussion__Sixth Edition. CLEAVELAND'S Pronouncing Medical Lexicon.—Thirteenth Edition. LEGO'S Guide to the Examination of the Urine. Second London Edition. HILL's Pocket Anatomist, for the use of Students. TANNER'S Memoranda Of Poisons.—From the Second London Edition. A complete Descriptive Catalogue of their Publications, together with a classified and priced list of all recent Medical Books, American and English, furnished or mailed free on application. LINDSAY & BLAKISTON, MEDICAL PUBLISHERS AND BOOKSELLERS, No. 25 South Sixth St., Philadelphia. THE SCIENCE AND PRACTICE OF SURGERY. WO loo 6s 1671 THE SCIENCE AND PRACTICE OF SURGERY; ¥\ .J $Uustraieb bg Jfoitr ;§trnbrcb anb JSebenig (Sftoob (Engrailing- ^&*tf FREDERICK JAMES GANT, F.R.C.S. BURGEON TO THE ROYAL FREE HOSPITAL, FORMERLY SOHGEON TO HER MAJESTY'S MILITARY HOSPITALS, CRIMEA AND SCUTARI. PHILADELPHIA: LINDSAY AND BLAKISTON. 1871. LONDON : SiVILL, EDWARDS AND CO., PRINTERS, CHANDOS STREET, COVENT GARDEN. PREFACE. It is now many years since a new systematic work representing the Science and Practice of Surgery, has appeared in this country. In offering this to the Profession, as the most recent one, I have endeavoured to introduce a full but condensed embodiment of all those changes in the Pathology and Treatment of Injuries and Diseases, Avhich the progress of Surgery has established. The leading features of this work are these:—It is essentially descriptive—not theoretical. In describing the various forms of Injury and Disease, I have endeavoured to present a sound and enlarged view of Surgical Pathology; but exhibiting, more particularly, the guiding elements of their pathology—whether for the purpose of study or re- ference. The whole is uniformly arranged under three heads—(1) Structural condition, with its Signs or Symptoms, and Diagnosis; (2) Causes, and Effects of the morbid condition; (3) Course, Ter- minations, Consequences, and Prognosis. The primary importance of all that pertains to the Diagnosis, or detection and discrimination of morbid conditions, has induced me to introduce a brief description of the healthy Anatomy of the part; wherever this seemed necessary or convenient, to clearly understand the nature of the structural alterations in Disease or Injury ; or for guidance in Surgical Operations. Thus will be found the Surgical Anatomy of the region or parts concerned, in rela- tion to Hernia;; and, of the Arteries, in connexion with Ligature. Physiology is interwoven with the Pathology of morbid conditions. (4) Treatment is fully considered—the pathological indications being stated, with guiding rules of treatment; and their fulfilment, both by medicinal agents—so far as the remedial efficacy of medical treatment may be at present known—and by the appropriate Surgical Operations or manipula- tions,—the design and performance of which are carefully described in detail. The various kinds of Surgical Instruments and Apparatus are also specially noticed, and their mode of application explained. Statistical Results of Treatment, are appended whenever usefully illus- trative of the curative value of Surgical Operations. The range of this work, in respect to its subject-matter, will be seen on perusing the Table of Contents. The Introduction presents a pre- VI PREFACE. liminary view of the nature of Surgery, as a Science and an Art; the latter, principally in regard to Operations, the Conditions favourable or unfavour- able for their performance ; the Arrangements necessary as to Instruments and Assistants; Anaesthetics, especially Chloroform ; the Dangers attending or consequent on Operations, and their Results. Then follows the recognised division of Pathology and Surgery into Two Parts—General, and Special; and the latter is arranged under Two Divisions—Injuries and Diseases of Textures, and those of Organs and Regions. Part I.—General Pathology and Surgery, comprising the forms of Disease which are common to all parts of the body, is made more com- prehensive than in other systematic works; it being the source of guidance in all Surgical Practice. This Part relates to Inflammation, Tu- mours or Morbid Growths, Degenerations, Ulceration and Mortification. Then follow also Diseases of the Blood—as Scrofula, Scurvy and Purpura, Rheumatism and Gout; Diseases of Contagious Origin—as Syphilis, Erysi- pelas, Pyaemia, Hospital Gangrene, Poisoned Wounds, Hydrophobia, Ma- lignant Pustule, Glanders ; Diseases of the Nervous System—Shock of In- jury, Prostration with Excitement, Tetanus. In Part II.—Special Patho- logy and Surgery, relating to the Textures, comprises the Injuries and Diseases of the Skin, and subjacent textures, in succession;—as Wounds, Burns, Cellulitis; Aneurisms, and Diseases of Arteries; Fractures, and Diseases of Bone; Dislocations, and Diseases of Joints; Deformities; Excisional Surgery of the Joints and Bones ; Amputations. As relating to Organs and Regions, this Division, beginning with the Head, and pro- ceeding downwards in the body, is made equally comprehensive, so as to include a condensed view of each Special Branch of Surgery. Thus, it embraces, Diseases of the Eye, Ear, and Teeth, which belong respectively to Ophthalmic, Aural, and Dental Departments of Surgical Practice. The Regional association of morbid conditions is especially calculated to facilitate the study of Diagnosis ; and the arrangement of pathological aud surgical knowledge—relative to each form of Injury and Disease, throughout the work, will be found most serviceable as a preparation for the order of Clinical investigation, and record of cases. By constantly having regard to the selection of essential matter, and pursuing the'uniform arrangement laid down; I have thus, also, I trust, simplified, and not inconsiderably abridged the size of this work, as compared with those of similar character. These features will perhaps make it better adapted for the use of Students, as a Surgical Text-book ; while, the wide range of subjects, may render it more completely serviceable to the Practitioner, for reference. The " Science and Practice" is quite independent of the Author's " Principles of Surgery," although the two works have this relation : the one forms a systematic description of injuries and diseases, taken in- PREFACE. vii dividually, in their pathology and treatment; the other is a systematic exposition of the guiding doctrines of all diagnosis, etiology, prognosis and therapeutics, from an original analysis of general pathology in the different classes of injury and disease. References to the Principles, for the con- venience of those readers who have that work, are indicated, in the course; of this work, by P. with the page, in brackets ; as thus, [P. p. .] As a general representation of Surgery, many sources of information have necessarily contributed; and it would be almost impossible to name individually, all those to whom by their published writings, I am indebted. The majority are acknowledged in foot-notes, or in the text. Some, whose labours have long since been established in surgical litera- ture, are omitted. Of more recent sources of original information, not hitherto gathered into a work of this kind, I may here more particularly mention my indebtedness to many of the elaborate treatises in " the System of Surgery," by various authors, edited by Mr. T. Holmes. Thus, taking them in alphabetical order, I am under obligation to— Mr. Birkett, on Hernia and on Diseases of the Breast; Dr. Brown- Sequard, on Diseases of the Nerves; Mr. Holmes Coote, on Diseases of the Thyroid Gland; Mr. J. Dixon, on Diseases and Injuries of the Eye; Dr. George Harley, on Apncea; Mr. E. Hart, on Aneurism ; Mr. Charles Hawkins, on Lithotrity ; Mr. Prescott Hewett, on Injuries of the Head; Mr. Hinton, on Diseases of the Ear; Mr. T. Holmes, on Aneurism, and on Diseases of the Bones ; Mr. T. K. Hornidge, on General Pathology of Fractures; Dr. G. M. Humphry, on Diseases of the Male Organs of Generation; Mr. Jonathan Hutchinson, on Surgical Diseases of Women ; Mr. Athol Johnson, on Diseases of the Joints; Mr. H. Lee, on Syphilis; Dr. W. J. Little, on Orthopaedic Surgery; Mr. T. Longmore, on Gunshot Wounds ; Mr. C. If. Moore, on Cancer ; Sir James Paget, on Tumours; Mr. A. Poland, on Urinary Calculi and Lithotomy; Mr. G. D. Pollock, on Diseases of the Mouth and Alimentary Canal; Mr. S. James. A. Salter, on Surgical Diseases connected with the Teeth; Mr. W. S. Savory, on Hysteria; Mr. A. Shaw, on Disease of the Spine ; Mr. J. Simon, on Inflammation; Mr. Henry Smith, on Diseases of the Rectum; Sir II. Thompson, on the Surgery of the Male Urinary Organs. I have also had recourse to other standard Treatises,recently published; and notably to—Hamilton, on Fractures and Dislocations; W. Adams, on Subcutaneous Surgery ; Mr. R. Barwell, on Lateral Curvature of the Spine; Lockhart Clarke, on Tetanus; John Wood, on Rupture; Mr. Christopher Heath, on Diseases of the Jaws; Mr. Butcher's Operative and Conservative Surgery; Sir William Fergusson's Practical Surgery; Curling, on Diseases of the Testis, and on Diseases of the Rectum. Many valuable Papers also in the Transactions of the Royal Medico- Chirurgical, and other Societies, have been levied; and Original Com- viii PREFACE. munications to the Medical Quarterlies and Weekly Journals. Nor have I hesitated to avail myself of the latest Editions of other Systematic Works on Surgery, already familiar to the Profession—the works of Erichsen, Pirrie, and Druitt; gleaning wherever I could find anything new and important, or specially considered. Lastly, I have to thank several of my Professional brethren for having favoured me with notes on points of experience; and Mr. Hancock, for having kindly placed at my disposal the unpublished MSS. of his valuable Lectures on the Surgery of the Foot and Hip,—as delivered at the Royal College of Surgeons. My own Pathological observations and Surgical experiences are inter- spersed throughout the work. Thus, I may be permitted to allude to Reparation in Wounds, Fractures, and after Injury of Arteries and Veins; Acupressure, Ligature, and Torsion of Arteries; the Pathological Condi- tions of Contused and Lacerated Wounds, of Compound Fractures, and of Compound Dislocations, which severally require Amputation; Disloca- tion of the Elbow-joint; Tumours; Degenerations; Polypus nasi; the Irritable Bladder; and, Diseases of the Joints, chiefly with reference to Excision,—being the Author's Lettsomian Lectures, on " Excisional Sur- gery," as delivered before the Medical Society of London, 1871. A carefully compiled Index, in conclusion, will be found convenient for reference. After all my labour I am fully conscious of many shortcomings in my endeavour to do justice to the present state of Surgery; but I must plead the unaided, single-handed production of the work, on a subject so comprehensive, and pursued for years amid the daily interruptions of Professional avocations, public and private. Of the Wood Engravings, 470 in number, which illustrate, and I trust adorn, the following pages, many are original,—the drawings having been taken from cases which have come under my own observa- tion. Those which relate to Excisional Surgery were drawn by Mr. C. D'xllton, with his well-known accuracy. But, with regard to the larger proportion of the engravings, I am under obligation to my Publishers, Messrs. J. and A. Churchill, who have aided me in the most liberal spirit, with regard to the whole of their large collections of unsur- passed Wood-blocks, which originally illustrated Sir Astley Cooper's " Fractures and Dislocations," edited by B. Cooper; those in Liston's " Practical Surgery;" and more recently in Fergusson's " Practical Sur- gery." Sir William Fergusson himself most readily concurred in this arrangement—an additional kindness to many others—and thus enabled me to enrich this work with a large assortment of instruments and apparatus peculiar to Modern Surgery; and also to illustrate the Operations which he has either devised or modified, and with which the association of his PREFACE. ix name is familiar; especially Lithotomy and Lithotrity, Operations for Tumours of the Jaws, and that for Cleft-Palate. My friends, Mr. John Wood, and Mr. William Adams, have equally obliged me in regard to the illustrations of their operations, for the Radical Cure of Hernia, and Subcutaneous Section of the Neck of the Femur. I have, moreover, to thank Mr. Heather Bigg, for having permitted me to select, aided by his own judgment and experience, any number of the wood-blocks I thought fit to use from his well-known Manual on " Orthopraxy." They are chiefly to be found in the Chapter on Deformities. Under cover, I have taken this opportunity of publishing that which will be useful to all those who may be preparing for Examina- tion at the Royal College of Surgeons of England, and which cannot fail to be interesting to the Profession at large,—a Guide to the Examina- tions for the Diplomas of Member and Fellow. It was written from personal observation during the last two years (1870-1); and, it exhi- bits the whole course of Examination in detail;—the nature of the Anatomical and Pathological Preparations, Surgical Instruments and Apparatus, and of the Questions, &c, submitted to Candidates,—in both the " Written" and " Practical," and of the " Primary," and "Pass," Examinations; with also the " Regulations" .of the College relating thereto. F. J. GANT. September, 1871. CONTENTS. INTRODUCTION. Surgery, as a primary division of Medicine ; as a Science and a Scientific Art. The relative importance of Diagnosis, Etiology, and Prognosis; and their relation, severally, to Treatment. The relative guidance of Pathological Anatomy and of Pathology. Also, in the design and performance of Surgical Operations. Com- parison of the Continental and English Schools of Surgery. Conditions Favourable and Unfavourable for Operation. Prepara- tion of Patient. Arrangements for Operation—The Room, Table, Instruments, Assistants. Anaesthetics. Historical notice. Chloroform—its Physiological Action. Phenomena or Symp- toms. Contra-indications to the employment of Chloroform, and exceptional Operations. Administration of Chloroform, and signs of anaesthesia. Inhalers. Death from Chloroform—by Asphyxia, Cardiac Syncope, Coma, persistent sickness. Treat- ment of an overdose. Other Anaesthetics—Nitrous Oxide or Laughing Gas. Sulphuric Ether. Bichloride of Methylene. Chloral. Local Anaesthesia. Freezing—by frigorific mixtures, ether-spray. Dangers attending, or consequent on, Surgical Operations. Dressing of the Wound, and Constitutional After- treatment. Results of Operation—Temporary, Permanent. Modes of Unsuccessful Results. PART I. GENERAL PATHOLOGY AND SURGERY. DISEASES OF NUTRITION. PAGB Chapter I.—Inflammation. Nutrition ......... 20 Inflammation . . . • • • . .23 Textural Changes, and State of the Circulation and" Blood-vessels ....... 23 XII CONTENTS. PAGB Nutrition—continued. Signs ...-••' Constitutional Symptoms—Inflammatory Fever Causes . External and Internal . Exciting and Predisposing Course and Terminations . Resolution . Effusion and Products . Suppuration and Abscess Ulceration . Mortification Treatment Local Constitutional Varieties of Inflammation . Chapter II.—Tumours or Morbid Growths. General Pathology, and Treatment Special Tumours Cysts and Cystic Tumours Fatty Tumour Fibro-cellular Tumour Painful Subcutaneous Tubercle Fibrous Tumour Recurring Fibroid, and Fibro-nucleated Tumours Cartilaginous Tumour—Enchondroma Myeloid Tumour Vascular or Erectile Tumour . Naevus ..... Aneurism by Anastomosis . Osseous and Glandular Tumours Infiltrating Growths—Cancer Encephaloid. Scirrhus. Colloid . Varieties ..... Cyst Formation Origin and Causes Course ..... Terminations .... Recurrence, and Secondary Cancer Treatment .... Operations .... Epithelial Cancer Chapter III.—Degenerations. Gfeneral Pathology and Treatment Special Degenerations 132 133 CONTENTS. xm PAGE Chapter IV.—Ulceration and Ulcers, Gangrene and Mortification. Ulceration.........134 Healthy Ulcer.......135 Inflamed Ulcer.......136 Irritable Ulcer.......136 CEdematous Ulcer.......137 Indolent and Varicose Ulcer.....137 Phagedaenic Ulcer . . . . . . .139 Haemorrhagic Ulcer . . . .139 Scorbutic Ulcer.......139 Scrofulous or Strumous Ulcer . . . .140 Cancerous Ulcer . . . . .141 Lupoid Ulcer ....... 141 Syphilitic Ulcer.......141 Gangrene and Mortification ...... 142 Causes ......... 143 Fever.........148 Treatment........149 Amputation ....... 151 DISEASES OF THE BLOOD. Chapter V.—Scrofula. General Symptoms . . . . . . .153 Special Forms . . . . . . . .153 Causes ......... 159 Treatment.........160 Scurvy and Purpura . . . . .162 Chapter VI.—Rheumatism and Gout. Rheumatism . . . . . . .165 Symptoms and Diagnosis. . . . . .165 Treatment . . . . . .167 Gout..........168 Symptoms and Diagnosis . ..... 168 Treatment . . . . . .171 DISEASES OF CONTAGIOUS ORIGIN. Chapter VII.—Syphilis. Local Syphilis........173 Chancre, and its Diagnosis . . . . .173 Bubo, and its Diagnosis . . . . . .176 Constitutional or Secondary Syphilis . . . .180 Skin Diseases.......181 Roseola........181 Lichen ........ 181 Tubercular eruption.....182 CONTENTS. Syphilis—continued. Lepra Psoriasis . Vesicular Eruptions . Pustular Eruptions . Ulceration of the Skin Diseases of Mucous Membrane Ulceration of Tonsils Syphilitic Iritis Chronic Enlargement of Testicle Diseases of Bones, and Periosteum Tertiary Symptoms Hereditary, Congenital, Infantile Syphilis Vaccino-Sjqmilitic Inoculation Unity or Duality of Syphilitic Virus Treatment ..... Local Syphilis Constitutional Syphilis . Syphilization .... Chapter VIII.—Erysipelas. Simple Erysipelas. .... Phlegmonous Erysipelas Causes ...... Treatment ...... Chapter IX.—Pyaemia or Purulent Infection. Symptoms . Secondary Abscesses Pathology . Exciting Causes . Treatment . Chapter X.—Hospital Gangrene. Signs ..... Origin and Course Causes .... Treatment .... Chapter XL—Poisoned Wounds. Hydrophobia Treatment Snake-bites .... Treatment . . . Malignant Pustule—Charbon. Treatment Glanders Treatment 182 182 182 182 183 183 183 185 185 186 187 187 189 191 192 192 193 198 200 201 205 206 209 209 210 215 216 216 217 221 222 223 226 228 229 229 230 230 230 CONTENTS. XV DISEASES OF THE NERVOUS SYSTEM Chapter XII.—Shock of Injury. Collapse. Symptoms and Diagnosis Causes .... Terminations Treatment . Prostration with Excitement Chapter XIII.—Tetanus. Symptoms and Diagnosis Varieties Pathology Causes.... Course, and Terminations Treatment . 232 232 233 234 235 236 237 238 240 241 241 PART II. SPECIAL PATHOLOGY AND SURGERY. Division I. INJURIES AND DISEASES OF TEXTURES. SKIN AND SUBJACENT TEXTURES. Chapter XIV.—Wounds—Incised Wound, Wounds DF Arteries and Ve INS. Incised Wound . 243 Reparation . 244 Immediate Union . 245 Primary Adhesion . 245 Suppurative Granulation and Cicatrization . 246 Healing under a Scab . 246 Modelling Process . . 247 . 248 Antiseptic Dressings . . 251 Theory of Antisepticism . 253 Results . 254 Wounds of Arteries . 255 Reparation . 256 Treatment . 258 Compression . . 259 Ligature . . 259 Acupressure . 261 Torsion . 264 XVI CONTENTS. Wounds—continued. Wounds of Veins ...... . 266 Entrance of Air into Veins ...... 267 Chapter XV—Contusion—Contused and Lacerated Wounds— Punctured Wounds. Contusion....... Treatment. ...... 270 Contused and Lacerated Wounds . 270 Treatment ...... 274 Amputation ..... 275 Punctured Wounds ..... 276 Treatment ...... 278 Chapter XVI.—Gunshot Wounds. Structural Conditions . . . . . .278 Projectiles ....... 282 Consequences ...... 284 Prognosis ....... 285 Treatment 285 Amputation ..... 288 Excision ..... 289 Chapter XVII.—Morbid Cicatrices. Deficient Cicatrix. . . . . . . .289 Excessive, and Exuberant—Cheloid Cicatrix . . .290 Painful Cicatrix........291 Ulceration—Growths and Degenerations of Cicatrix . 291 Chapter XVIII.—Burns and Scalds. Lightning. Frost-bite. Burns and Scalds ...... . 292 Course and Terminations. 294 Treatment ..... 297 Lightning ...... 299 Frost-bite ...... 300 Chapter XIX.—Cellulitis. Carbuncle, and Boils. Cellulitis...... . 301 Symptoms and Diagnosis. . 301 Treatment ..... . 302 Carbuncle or Anthrax . . 302 Treatment ..... . 303 Boil or Furunculus .... . 304 Chilblain ...... • 305 Whitlow or Paronychia • 305 Onychia . . . 307 In-grown Toe-nail .... . 307 Corns. Horns. Warts . 308 CONTENTS. xvu MUSCLES AND TENDONS. Chapter XX.—Sprain. Rupture. Tumours. Sprains or Strains Rupture of Muscle and Tendon Reparation Treatment Displacement of Tendon Inflammation of Muscle Tumours .... BURSAE AND SHEATHS OF TENDONS. Chapter XXI.—Inflammation. Ganglion. 309 309 310 311 312 312 313 Inflammation of Bursae ..... . 314 Of Bursae Patellae ..... . 315 Bunion ....... . 315 Tenosynovitis ...... . 316 Ganglion ....... . 317 NERVES. Chapter XXII.—Injuries. Neuritis. Neuralgia. Injuries ....... . 318 Neuritis ....... . 318 Neuralgia ....... . 319 ARTERIES. Chapter XXIII.—Aneurism. Structural Conditions ...... . 321 Circumscribed—True Aneurism . 321 Diffused—False Aneurism . . 321 Fusiform or Tubular Aneurism . 321 Signs ......... . 322 Diagnosis ........ . 323 Causes ........ . 323 Course and Terminations . . 325 Spontaneous Cure ...... . 325 Treatment ........ . 328 Compression ....... . 329 Ligature ....... . 332 Manipulation ....... . 339 Galvano-puncture ...... . 340 Injection ....... . 341 Treatment of Traumatic Aneurism . 342 Aneurismal Varix and Varicose Aneurism . 343 Signs ........ . 344 Causes ........ . 345 Treatment ....... 6 . 345 xviii CONTENTS. PAGS Chapter XXIV.—Aneurism of Special Arteries. Arch of Aorta.......• 347 Aneurisms at Root of Neck ....•• Qfll Treatment........001 OKI Innominate Aneurism . . . • Aneurisms of Right Carotid and Subclavian Arteries 352 Carotid Aneurism......352 Subclavian Aneurism.....353 Aneurism of Carotid Artery.....353 Wounds and Traumatic Aneurism .... 355 Aneurismal Varix .....•• 35o Aneurism of Internal Carotid . . . . . 3o5 Extra-cranial ...-•••• 355 Intra-cranial . . . . • . • • 355 Wounds, and Traumatic Aneurism of Internal or External Carotids ...... 358 Aneurism of Subclavian Artery ..... 358 Wounds and Traumatic Aneurism . . . .359 Aneurismal Varix . . . . . . .359 Aneurism of Axillary Artery ..... 359 Wounds and Traumatic Aneurism .... 360 Aneurisms of Brachial, Radial, and Ulnar Arteries . 360 Wounds and Traumatic Aneurism . . . .361 Aneurismal Varix, and Varicose Aneurism . . 361 Aneurism of Abdominal Aorta ..... 362 Aneurisms of Iliac Arteries—Common, Internal, and External.........362 Aneurisms of Gluteal, Sciatic, and Pudic Arteries . . 363 Wounds, and Traumatic Aneurism of Gluteal Artery 363 Aneurism of Common Femoral Artery .... 364 Wounds and Traumatic Aneurism .... 365 Aneurismal Varix, and Varicose Aneurism . .365 Aneurism of Femoral Artery—Deep and Superficial Femorals ......... 365 Wounds and Traumatic Aneurism . . . .366 Aneurismal Varix, and Varicose Aneurism . . 367 Aneurism of Popliteal Artery ..... 367 Wounds and Traumatic Aneurism . . . .369 Aneurisms of Tibial Arteries—Anterior and Posterior .. 369 Aneurismal Varix, and Varicose Aneurism . . 370 Chapter XXV.—Ligature of Arteries. Ligature of an Artery in its continuity .... 370 Ligature of an Artery at the seat of Wound . . . 372 Ligature of Innominate Artery ..... 379 CONTENTS. XIX PAGE Ligature of Arteries—continued. Surgical Anatomy .... . 372 Operation ..... . 373 Ligature of the Common Carotid Artery . 374 Surgical Anatomy .... . 374 Operation ..... . 375 Ligature of the External and Internal Carotid Arteries . 375 Surgical Anatomy .... . 375 Operation ..... . 376 Ligature of the Surgical Artery . 376 Surgical Anatomy .... . 376 Operation ..... . 377 Ligature of the Subclavian Artery . 377 Surgical Anatomy .... . 377 Operation ..... . 379 Ligature of the Axillary Artery . 380 Surgical Anatomy .... . 380 Operation ..... . 382 Ligature of the Brachial Artery . 382 Surgical Anatomy .... . 382 Operation ..... . 384 Ligature of the Radial Artery . 384 Surgical Anatomy .... . 384 Operation ..... . 385 Ligature of the Ulnar Artery . 385 Surgical Anatomy .... . 385 Operation . 386 Ligature of the Abdominal Aorta, and of Iliac Arteries— Common, External, and Internal . 386 Surgical Anatomy . . . . . . 386 Operation—External Iliac . 388 ,, Internal Iliac . 389 „ Cornmon Iliac . 389 ,, Abdominal Aorta . . 389 Ligature of the Femoral Artery—Common and Superficial 3^9 Surgical Anatomy .... . 389 Operation—Common Femoral Artery . 392 ,, Superficial Femoral Artery . 392 Ligature of the Popliteal Artery . 393 Surgical Anatomy .... . 393 Operation ..... . 394 Ligature of the Anterior Tibial Artery . . 395 Surgical Anatomy .... . 395 Operation . . . . . 396 Ligature of the Posterior Tibial Artery . . 397 b 2 XX CONTENTS. Ligature of Arteries—continued. Surgical Anatomy ...... Operation ...... Peroneal Artery . Chapter XXVI.—Diseases of Arteries. Arteritis ........ Ossification ........ Senile Gangrene ...... VEINS. Chapter XXVII.—Injuries, Varicose Veins, Phlebitis. Varicose Veins or Varix ..... Phlebitis........ Phlebolithes or Vein-Stones ..... LYMPHATICS AND GLANDS. Chapter XXVIII.—Lymphatitis. Tumours. Lymphatitis—Inflammation of the Lymphatics Adenitis—Inflammation of Lymphatic Glands Enlargements and Tumours .... BONES. Chapter XXIX.—Fracture. Fractures Signs Diagnosis Causes . Reparation Treatment Compound Fracture Treatment .... Amputation Complicated Fracture . Treatment .... Diseased Callus, and Deformed Union Treatment .... Ununited Fracture, and False Joint. Disunited Fracture Treatment ....... Chapter XXX.—Special Fractures. Fractures of the Facial Bones Nasal Bones Malar Bone . Zygoma Upper Jaw . Lower Jaw . 397 397 399 399 400 401 403 407 408 409 410 411 411 413 414 414 415 417 424 425 427 431 431 432 433 433 437 441 441 442 442 442 443 CONTENTS. Special Fractures—continued. Fractures of the Hyoid Bone >? „ Ribs, and Costal Cartilages » „ Sternum v >> Clavicle » „ Scapula >> ,, Humerus „ ,, Ulna . » ,, Radius and Ulna >> ,, Radius » » Carpal, Metacarpal Bones, and Fingers » „ Innominate Bones » ,, Sacrum ,, ,, Coccyx „ ,, Femur ,, „ Patella n j, Tibia . „ „ Fibula )i „ Tarsal, Metatarsal Bones, and Toes Chapter XXXI.—Diseases of Bone. Ostitis, or Inflammation of Bone Scrofulous Ostitis Syphilitic Ostitis Periostitis . Endostitis Suppuration Osteo-myelitis Diffuse Periostitis Circumscribed Abscess of Bone Caries Necrosis Rachitis or Rickets Mollities Ossium . Fragilitas Ossium Tumours Exostosis Enchondroma Fibrous Tumour Cysts Cystic Tumours Hydatid Cysts Cancer—Interstitial ,, Periosteal . Pulsatile Tumour, and Osteo-Aneurism Diseases of Particular Bones . xxi PAGB 443 444 446 446 449 452 457 460 461 463 463 465 466 466 474 478 478 483 484 485 485 485 486 487 487 488 489 490 493 497 498 500 500 500 501 501 501 502 502 503 503 505 505 xxii CONTEXTS. JOINTS. PAGB Chapter XXXII.— Injuries. Sprains. Wounds. Dislocations. Sprains or Strains ..... . 506 Wounds . 506 Dislocations . 508 Signs . 508 Diagnosis . 509 Causes . 510 Reparation . 510 Treatment . 512 Compound Dislocation ..... . 518 Treatment . 519 Amputation ..... . 520 Complicated Dislocation .... . 521 Treatment . 522 Unreduced Dislocation and False Joint . . 522 Treatment . 524 Congenital Dislocations .... . 526 Chapter XXXIIL— -Special Dislocations. Dislocations of the Lower Jaw . 527 >> » Spine .... . 529 » » Clavicle .... . 529 » >> Scapula .... . 532 » >> Shoulder-joint . . 532 »> » Sub-glenoid . . 532 >» >> Sub-clavicular . 533 )> n Sub-spinous . . 533 >> >> Elbow-joint . 538 Radius and Ulna . . 538 Ulna . . 540 Radius . 541 » » Inferior Radio-Ulnar Articula it ion . 545 » >> Radio-carpal Articulation . . 546 »> » Carpal Bones . . 547 >1 ,, Metacarpal Bones . 548 » >> Phalangeal Bones . 548 » » Pelvis .... . 550 »» >) Hip-joint . 551 On the Dorsum Ilii . 551 Into Great Ischiatic Notch • 551 Into Obturator Foramen . 556 Upon the Pubes . . 558 Anomalous Dislocations • 559 » » Patella .... . 560 )> » Knee-joint • 562 CONTENTS. xxiii pag» Special Dislocations—continued. Dislocations of the Fibula......566 Ankle-joint . . . . . 566 Astragalus . . . . .569 other Tarsal Bones . . . .570 Metatarsal Bones . . . .571 Phalangeal Bones .... 572 Chapter XXXIV.—Diseases of Joints. Synovitis.........572 Chronic Rheumatic Synovitis or Arthritis . . . 575 Scrofulous Synovitis.......577 Scrofulous Disease or Caries......579 Ulceration of Articular Cartilages.....582 Anchylosis, or Stiff Joint......584 Loose Cartilages . . . . . . . .586 Tumours ......... 587 Neuralgia.........588 Chapter XXXV.—Diseases of Particular Joints. Diseases of the Hip-joint......588 Scrofulous Disease—Morbus Coxarius . . . 588 Chronic Rheumatic Arthritis—Morbus Coxae Senilis 592 Neuralgia ........ 592 Disease of the Sacro-iliac Joint.....592 Chapter XXXVI.—Deformities. Deformities of Face and Neck . . . . .594 Wry-neck or Torticollis . 594 Strabismus or Squint 596 Deformities of the Arm and Hand 597 Deformities of the Leg . 598 Knock-knee .... 598 Bowed or Bandied Legs . 599 Contraction of Knee-joint 599 Talipes or Club-foot 600 Talipes Equinus 601 Talipes Varus 602 Talipes Valgus 604 Flat or Splay Foot . 604 Talipes Calcaneus . 605 Varieties of Club-foot 605 Chapter XXXVII.—Excisional* Surgery of the Joints and Bones. Of the Joints, for Disease ...... 606 Joint Excision, and the General Treatment of Joint- Disease ........ 607 xxiv CONTENTS. fags Excisional Surgery of the Joints—continued. General Conditions of Disease for Excision . • 608 Operation of Joint Excision.....610 Instruments, and General Directions . . • 610 After-treatment . . . • • .oil Repair after Excision . . . . • .613 Excision compared with Amputation . . .613 „ „ ,, Natural Cure by Anchylosis 614 General Results.......614 Special Joints.......615 Knee-joint—Conditions for Excision . . . .615 Operation ....•••• 616 After-treatment . . . • • • .619 Results—in relation to Natural Anchylosis . . 620 „ „ Mortality.....620 Statistics, British and Foreign . . . .621 Hospitals of England and Scotland (Author's CoUection) .......621 Compared with Amputation in the Thigh . .622 State of the Limb......622 Re-excision ........ 624 Secondary Amputation ...... 624 Typical Cases of Knee-joint Excision (by Author) . 625 Analysis of the Cases . . . . . .629 Hip-joint—Conditions for Excision . . . .631 Operation ........ 634 After-treatment ... . . . . .635 Results in relation to Mortality . . . .636 Statistics, British and Foreign .... 637 Hospitals of England and Scotland (Author's Collection).......638 Compared with Hip-joint Amputation . . 639 State of the Limb......639 Section of Neck of Femur ..... 639 Typical Cases of Hip-joint Excision (by Author) . 641 Analysis of the Cases ...... 642 Ankle-joint—Conditions for Excision .... 643 Operation ........ 644 After-treatment ....... 644 Results in relation to Mortality .... 645 Statistics, British ...... 645 Hospitals of England and Scotland (Author's Collection).......645 Compared with Amputation of the Leg . .645 ,, ,, at Ankle-joint (Syme's) . 646 (Pirogoff's) 646 CONTENTS. XXV Excisional Surgery of the Joints—continued. State of the Foot Secondary Amputation Tarsal Bones—Conditions for Excision Excision of Astragalus Results ..... Excision of Os Calcis Results ..... Compared with sub-astragaloid Amputation Excisions of Cuboid, Scaphoid, and Cuneiform Bones Excision of Metatarsal Bones and Toes Elbow-joint—Conditions for Excision .... Operation ........ After-treatment ....... Results in relation to Mortality .... Statistics, British and Foreign .... Hospitals of England and Scotland (Author's Collection) ....... Compared with Amputation of the Arm State of the Limb ...... Re-excision ........ Secondary Amputation . . ... Typical Cases of Elbow-joint Excision (by Author) . Shoulder-joint—Conditions for Excision Operation ........ After-treatment ....... Results in relation to Mortality .... Statistics, British and Foreign .... Hospitals of England and Scotland (Author's Collection) State of the Limb \\rrist—Conditions for Excision Operations Lister's Operation . After-treatment Results in relation to Mortality .... Hospitals of England and Scotland (Author's Collection) ...•••< Hand—Metacarpal, and Phalangeal Bones . 646 646 646 647 647 647 648 649 649 649 650 651 652 652 653 653 653 653 655 655 655 656 656 657 657 657 657 658 660 661 663 665 666 666 667 EXCISION OF THE JOINTS FOR INJURY. Knee-joint—Conditions for Excision Operation ...•••• After-treatment ...... Results in relation to Mortality 667 667 668 668 xxvi CONTENTS. FAGB Col- Excisional Surgery of the Joints—continued. Hospitals of England and Scotland (Author's Collection) Hip-joint—Conditions for Excision Operation, and After-treatment Results in relation to Mortality Ankle-joint—Conditions for Excision Operation, and After-treatment Results in relation to Mortality Hospitals of England and Scotland (Author' lection) ...... Compared with Amputation of the Leg State of the Foot .... Shoulder-joint—Conditions for Excision Operation and After-treatment Results in relation to Mortality ,, compared with Secondary Excision „ „ with Natural Cure „ „ with Amputation at Shoulder-joint „ Hospitals of England and Scotland (Author's Collection) ...... Elbow-joint—Conditions for Excision .... Operation and After-treatment .... Results in relation to Mortality .... ,, compared with Amputation of Arm „ „ with Secondary Excision „ Hospitals of England and Scotland (Author's Collection) ...... Wrist—Conditions for Excision ..... Operation and After-treatment .... Results in relation to Mortality .... „ Hospitals of England and Scotland (Author's Collection) ...... EXCISION OF BONES. Scapula—Conditions for Excision . Operation .... With Amputation at Shoulder-joint Clavicle Operation Radius, or Ulna .... Tibia, or Fibula .... Chapter XXXVIII.—Amputations. General Directions Instruments .... Operation—Flap and Circular . „ Relative Merits 669 669 670 670 671 671 671 671 671 671 672 672 672 672 673 673 673 674 674 674 674 675 675 675 676 676 676 676 677 678 678 678 680 680 680 681 683 CONTENTS. XXVll "UTATIONS— -continued. Operation—Amputation by Rectangular Flaps . . 684 Dressing of Stump . 684 Morbid Conditions of Stump . . 685 Healthy Stump ■ . 687 Double Amputation . 687 Results of Amputation . 688 For Injury and Disease . 689 Primary and Secondary . 689 Causes of Death . . 690 Particular Amputations of the Fingers . 690 >> >j of the Thumb . 692 >> >) of the Little Finger . 693 »> >) at the Wrist-joint Artificial Hands . 693 . 693 >> o of the Fore-arm Artificial Fore-arm . 693 . 694 n M of the Arm Results. Artificial Arms . 694 . 695 . 696 >i )) at Shoulder-joint Results . . 696 . 697 >> >> of the Toes . 697 n >l of the Great Toe . 697 >J )J of the Little Toe . 698 >> » of the Toes, at Tarso Metatarsal Articulations—Hey's Operation 698 » )) through the Tarsus—Chopart's Operation . 699 >l >) at Ankle-joint—Syme's Operation 700 >J )) Pirogoff's . 701 >) )) Sub-astragaloid Amputatio n . 701 Hancock's Amputation . 702 Artificial Foot . 703 of the Leg . 703 Artificial Legs . 704 Results . . 704 )} >) at Knee-joint . . 704 )) )) Supra - condyloid Amp itation 706 Results, at Knee-joint . 706 }) » of the Thigh . . 706 Forms of Artificial Leg . 709 Results . . 710 'J )) at Hip-joint . 710 }} Below Trochanters . 711 Results, at Hip-joi nt . 712 xxviii CONTENTS. SPECIAL PATHOLOGY AND SURGERY. Division II. INJURIES AND DISEASES OF ORGANS AND REGIONS. PAGB THE HEAD. Chapter XXXIX.—Injuries and Diseases of the Scalp, Cranium, Membranes of the Brain, and Brain. Injuries of the Scalp Wounds. Contusion Cephalhaematoma . Injuries of the Cranium Contusion of the Bone Fractures—of Vault of the Skull „ of Base of the Skull Injuries of the Membranes of the Brain. Extravasation of Blood, within the Cranium Hernia Cerebri Injuries of the Brain Concussion Contusion Compression . Wounds. Injuries of the Cranial Nerves . Traumatic Inflammation . Abscess .... Trephining .... Tumours of the Head . Cysts or Wens Vascular Tumours—Naevi Exostosis .... Fibrous or Fibro-cystic Tumour Myeloid Tumour . Cancer ..... Fungous Tumour of Dura Mater Congenital Hernial Tumours . Hydrocephalus and Paracentesis Capitis ORGANS OF SPECIAL SENSE, AND THEIR APPENDAGES. Chapter XL.—Ophthalmic Surgery, or Injuries and Diseases of the Eye and its Appendages. Injuries ..... 733 Wounds—of Eyebrows and Eyelids .... 733 „ of Eyeball......733 CONTENTS. XX1X Ophthalmic Surgery—continued. PAGB Contusion ....... . 734 Foreign Bodies ...... . 735 Diseases of Eyelids ...... . 736 Hordeolum, or Stye . . . . . . 736 Abscess in Meibomian Follicles . 736 Ophthalmia Tarsi ...... . 736 Trichiasis ....... . 737 Entropion ....... . 737 Ectropion ....... . 737 Epicanthus ....... . 738 Ancyloblepharon ...... . 738 Symblepharon ...... . 738 Lagophthalmos ...... . 738 Ptosis ........ . 738 Spasmodic Twitching of Eyelid . 739 Hysterical Affections .... . 739 Tumours ....... . 739 Lice ....... . 739 Of Lachrymal Apparatus .... . 739 Tumours of Lachrymal Gland . . 740 Lachrymal Obstructions—Epiphora . . 740 Obstruction of Nasal Duct and Fistula Lachrym alis . 740 Dacryolithes ...... . 742 Detached Eyelash ..... . 742 Of the Conjunctiva ..... . 742 Conjunctivitis, or Ophthalmia . 742 Catarrhal Ophthalmia . 743 Pustular Ophthalmia .... . 743 Purulent Ophthalmia.... . 743 ,, ,, in New-born Infants . 744 Gonorrhoeal Ophthalmia . 745 Scrofulous Ophthalmia . 745 Granular Conjunctiva . 746 Growths of Conjunctiva . 746 Pterygium ..... . 746 Pinguecula ..... . 747 Tumours ..... . 747 Cysticercus telae Cellulosae . 747 Nitrate of Silver Stains . . 747 Of the Cornea...... . 747 Corneitis, or Keratitis . 747 Chronic Interstitial .... . 748 Opacities ...... . 748 Ulcers ...... . 748 Staphyloma ..... . 749 CONTENTS. Ophthalmic Surgery—continued. Conical Cornea ...... . 749 Arcus Senilis ...... . 749 Of the Sclerotic ....... . 749 Sclerotitis—Rheumatic Ophthalmia . 749 Of the Iris ....... . 751 Iritis ....... . 751 Syphilitic Iritis . . 751 Rheumatic Iritis . . 752 Scrofulous Iritis . . . . . . 752 Adhesions of Iris . . . . . . 753 Staphyloma Sclerotica? . . 753 Cysts of Iris ..... . 753 Myosis and Mydriasis . 753 Artificial Pupil .... . 754 Of the Lens and Capsule . . . . . . 755 Cataract ...... . 755 Operations for . . . . . . 757 On Infants . . . . . . 761 Of the Choroid and Retina . . . . . 761 Choroiditis and Retinitis . 761 Dimness of Sight .... . 761 Defective Sight .... . 762 Impaired Vision . . . . . . 762 Muscae Volitantes . . . . . 762 Amaurosis ..... . 762 Ophthalmoscopic Appearances . 763 Ophthalmoscope .... . 765 Healthy appearance of Eye . . 766 Glaucoma ..... . 767 Iridectomy ..... . 768 Short Sight—Myopia . 768 Long Sight—Presbyopia . . 769 Colour-blindness—Acritochromacy . 769 Day sight—Hemeralopia . 769 Night sight—Nyctalopia . 769 Of the Eyeball, or of its Motor Apparatus . 769 Protrusion of Eyeball . 769 Dislocation ..... . 770 Tumours ..... . 770 Removal of Eyeball .... . 770 Strabismus or Squint . 771 Chapter XLI.—Injuries and Diseases of the Ear. External Ear...... . 773 Wounds ...... ■ 773 CONTEXTS. Injuries and Diseases of the Ear—continued Foreign Bodies Displacement .... Hypertrophy .... Eczema ..... Wax in Meatus Thickening of Cuticle Polypus .... Otorrhcea .... Fungous Granulations Internal Ear .... Ostitis ..... Artificial Membrana Tympani . Collapse of Eustachian Tubes—Throat Deafness Ear-ache—Otalgia Deafness .... Chapter XLII.—Injuries and Diseases of Foreign Bodies Epistaxis Hypertrophy or Lipoma Cancer Lupus Syphilitic Ulcer . Ozaena or Rhinorrhcea . Thickening of Schneiderian Membrane Polypus Gelatinous or Mucous Fibrous . Cancerous Tumours of Septum Calculi or Rhinoliths Plastic Surgery of Nose—Rhino-plastic Operations Chapter XLIIT.—Injuries and Diseases of the Mouth. Lips—Wounds ..... Hare-lip ...... Congenital Transverse Fissures of Cheeks Congenital Contraction of Mouth . Cheiloplastic Operations of Lower Lip . of Upper Lip . Diseases—Hypertrophy Ulceration the Nose XXX1 PAG9 773 773 774 774 775 775 775 776 777 777 777 779 779 779 780 780 781 781 783 783 783 784 784 785 786 786 788 788 788 791 791 795 795 798 798 798 798 799 798 799 xxxii CONTENTS. Injuries and Diseases of the Mouth—continued. Tumours Encysted Erectile Epithelial Cancer Cheeks—Wounds, and Salivary Fistula Tumours Corroding Ulcers Cancrum Oris Ton gue—Woun d s Foreign Bodies Tongue-tie Prolapsus Glossitis Tumours—Cancer Erectile Fatty Ranula Cysts Gums and Teeth—Diseases Alveolar Abscess—Gum-boil or Parulis Epulis . Congenital Hypertrophy of Gum Polypus . Vascular Tumours Teeth—Injuries and Misplacements Eruption of Milk-teeth . Mal-eruption of Wisdom Teeth Irregularities of Permanent Teeth Diseases—Caries and Necrosis Haemorrhage after Tooth-extraction Chapter XLIV.—Diseases of the Jaws. Cleft-palate . Staphyloraphy—Operation of Necrosis of Jaws . Abscess of Antrum Dropsy of Antrum Tumours of Upper Jaw of Lower Jaw Excision of Upper Jaw „ Lower Jaw Closure of the Jaws Excision of Articulation 799 800 800 800 801 801 801 802 802 803 803 803 804 804 807 807 807 807 808 808 809 809 810 810 811 811 811 811 811 813 814 814 817 818 819 820 820 821 822 824 826 827 CONTENTS. XXX1U THE NECK. Chapter XLV.—Injuries of Larynx and Trachea, Pha- rynx, AND O3S0PHAGUS. Wounds of the Throat—Cut-throat . . .827 Foreign Bodies in the Air-passages .... 830 Scalds of the Glottis, Mouth, and Pharynx . . 832 Asphyxia or Apnoea.......832 Artifical Respiration .... 835 Foreign Bodies .... 836 Pharyngotomy and OZsophagotomy . . . .838 Chapter XLVL—Diseases of Pharynx and (Esophagus, Larynx, and Trachea. Tonsillitis ...... 838 Chronic Enlargement of Tonsils.....839 Elongation or Relaxation of Uvula .... 840 Tumours of Velum Palati......841 Pharyngitis........841 Tumours of the Pharynx......842 Stricture of Oesophagus......842 Gastrotomy ...... 843 Paralysis of Oesophagus ...... 844 Dilatation and Sacculation ...... 844 Use of Stomach-pump ....... 844 Laryngitis.........845 Laryngoscope ........ 845 Laryngoscopy. . . . . . . .846 Treatment of Laryngeal Affections .... 847 Laryngotomy and Tracheotomy ..... 848 Chapter XLVII.—Diseases of the Thyroid Gland. The Parotid Gland. Tumours of the Neck. Thyroid Gland. Bronchocele or Goitre ...... 850 Inflammation of Thyroid Gland .... 853 Fibrous, Cartilaginous, and Osseous Formations. Tubercle. Cancer ... ... 853 Hernia Bronchialis ....... 853 Parotid Gland. Parotitis or Mumps ...... 853 Glandular Parotid Tumour ..... 853 Tumours in Parotid Region ..... 854 Tumours of the Neck. Enlargement of Cervical Glands . . . .855 Induration of the Sterno-mastoid Muscle . . . 855 XXXIV CONTENTS. Diseases of the Thyroid, &c.—continued. Enlarged Bursae ..•••• Cysts ...•■••• Fatty, and other Tumours . Chapter XLVIII.—Injuries and Diseases of the Spine. Anatomy and Physiology of Spine or Vertebral Column Wounds . Sprains . Intra-spinal Haemorrhage Inflammation of Joints of Spine Fractures . Dislocation .... Concussion of Spinal Cord . Spinal Meningitis . Spinal Myelitis Compression of Spinal Cord . Disease of the Spine Psoas Abscess Varieties of Spinal Abscess Disease of Atlas and Axis Lateral Curvature Posterior Curvatures—Cyphosis and Lordosis Spina Bifida . THE THORAX. Chapter XLIX.—Injuries of Thoracic Parietes, and Organs. Wounds of Parietes of Chest ... . 882 882 886 886 886 887 887 855 855 856 856 857 857 858 858 859 859 861 862 862 867 867 869 870 872 873 880 881 Wounds involving Thoracic Organs Hernia of Lung or Pneumatocele Pneumothorax Emphysema . Haemothorax . Hydrothorax Empyema Paracentesis Thoracis Hydrops Pericardii . Deformity of Chest . Chapter L.—Diseases of the Breast. Physiological and Anatomical Relations of Mammary Gland .... General Pathology and Diagnosis . Method of Examining the Breast Inflammation, or Mastitis Scrofulous Enlargement . 889 889 890 891 891 892 893 CONTEXTS. XXXV Diseases of the Breast—continued. Inflammation of Nipple Chronic Induration Irritable Mamma Hypertrophy Atrophy Tumours Adenocele or Adenoid Tumour Fibrous Tumour—Neuroma . Fatty Tumour Cartilaginous and Osteoid Tumours Cysts and Cystic Tumours Cancer—Scirrhus Encephaloid Colloid . Recurrent Cancer Amputation of Breast Functional Disorders of Breast Abnormal Secretion of Milk Excessive Lacteal Secretion, or Galactorrhoea Deficient Lacteal Secretion, or Agalactia Congestion with Milk Diseases of Male Breast Anomalies of Development Absence of Breast Supernumerary Breasts or Nipples THE ABDOMEN. Chapter LI.—Injuries of Abdominal Parietes, and Viscera. Contusion . Wounds of Parietes Injuries implicating Viscera . Rupture or Penetrating Wound Protrusion .... Traumatic Peritonitis Chapter LII.—Hernia. General Pathology of Abdominal Hernia Situations of Herniae . Names of Herniae Causes Reducible Hernia Treatment—Taxis Radical Cure—Operations for Irreducible Hernia c 2 xxxvi CONTENTS ■ FAG' Hernia—continued. Treatment ... .922 Incarcerated . 922 Strangulated . 923 Diagnosis . 924 . Operation—Herniotomy . . 928 Results . 935 Artificial Anus . 935 Double Hernia . 937 Chapter LIH.—Special Hernle. Inguinal Hernia . . . . . . . .938 Oblique Inguinal Hernia . 938 Anatomy . 939 Seat of Stricture . 940 Direct Inguinal Hernia . . 940 Anatomy - . 940 Seat of Stricture . 941 Signs of Inguinal Hernia . 941 Congenital Hernia . . 942 Infantile or Encysted Hernia . 944 Diagnosis of Inguinal Hernia . 945 Treatment .... . 948 Reducible, and Trusses . 948 Radical Cure. Operations . 950 Irreducible .... . 957 Strangulated. Operation . . 957 Congenital Hernia . 958 Infantile or Encysted . . 959 Femoral or Crural Hernia . 959 Anatomy ..... . 960 Seat of Stricture .... . 962 Varieties . . . . . . 962 Signs and Diagnosis. . 963 Treatment ..... . 965 Reducible, and Trusses . 965 Radical Cure. Operation . 965 Irreducible .... . 967 Strangulated. Operation . . 967 Umbilical Hernia..... . 970 Anatomy ..... . 970 Seat of Stricture . . . . . 971 Signs ...... . 971 Treatment ..... . 972 Reducible, and Trusses . 972 CONTENTS. Special Hernia—continued. Irreducible Strangulated. Operation . Ventral Hernia . Lumbar Hernia . Obturator or Thyroid Hernia Perinaeal Hernia . Vaginal Hernia . Pudendal Hernia . Ischiatic Hernia . Diaphragmatic Hernia xxxvn PAGB . 973 . 973 . 973 . 974 . 974 . 975 . 975 . 975 . 976 . 976 Chapter LIV.—Intestinal Obstruction. Intestinal Conditions or Causes Symptoms and Diagnosis Treatment ..... Gastrotomy .... Colotomy .... Chapter LV.—Paracentesis Abdominis. Operation of Tapping Abdomen ..... Chapter LVI.—Diseases, Injuries, and Malformations Rectum and Anus. Diseases ...... Inflammation and Rectal Abscess Fistula in Ano .... Ulcer of Rectum, and Fissure of Anus Haemorrhoids—External and Internal Prolapsus of Rectum Polypus of Rectum . Stricture of Rectum Rectal Fistula Recto-Vesical Recto-Vaginal Anal Tumours Anal Contraction Injuries Wounds Foreign Bodies Congenital Malformations Imperforate Anus . Imperforate Rectum Rectal Communications with Bladder, Vagina, Pe- rinaeum ...•••• 977 978 979 981 982 983 985 985 986 991 993 1002 1005 1007 1010 1010 1011 1012 1012 1012 1012 1013 1014 1014 1014 1016 XXXV111 CONTENTS. Functional Disorders ...... 1017 Atony of Rectum ....... 1017 Irritable Rectum, or Sphincter 1017 Neuralgia of Rectum, or Anus 1018 Pruritus Ani ....... 1018 THE GENITO-URINARY ORGANS. Chapter LVH—Injuries and Diseases of the Bladder— and Urinary Calculus. Injuries ........ 1019 Laceration and Rupture of Bladder . 1020 Rupture of Ureter ...... 1020 Foreign Bodies ....... 1020 Urinary Calculus....... 1021 Origin and Production ..... 1021 Physical Properties ..... 1022 Structure ....... 1022 Chemical Composition ..... 1023 Relative frequency of different Calculi 1023 Uric or Lithic Acid Calculus .... 1024 Tests....... 1024 Urate of Ammonia Calculus .... 1024 Tests....... 1024 Urates of Soda or Lime ..... 1024 Uric or Xanthic Oxide ..... 1024 Tests....... 1024 Cystic Oxide or Cystine Calculus . • . 1024 Tests....... 1025 Fibrinous Calculus ...... 1025 Tests....... 1025 Uro-Stealith Calculus ..... 1025 Tests....... 1025 Blood Calculus ...... 1025 Tests....... 1025 Carbonate of Lime Calculus .... 1025 Tests....... 1025 Oxalate of Lime Calculus .... 1026 Varieties ....... 1026 Tests....... 1026 Phosphate of Ammonia and Magnesia-Triple Phos- phate Calculus ..... 1026 Tests . '...... 1026 Phosphate of Lime ...... 1026 Tests....... 1026 CONTENTS. Injuries and Diseases of the Bladder—continued. Phosphate of Lime, and Phosphate of Magnesia Ammonia—Mixed Phosphates—Fusible cuius .... Tests .... Silicious Calculus . Tests .... Chemical Examination of Calculi Appliances and Tests Order of Examination Table for Examining Urinary Calculi Causes of Urinary Calculi Climate and Locality . Hereditary tendency . Sex . Period of Life or Age Habits of Life . Morbid conditions of Urinary Organs Renal Calculus Treatment Stone in the Bladder Symptoms, and Sounding the Bladder Encysted Calculus Diagnosis . . • • Consequences and Terminations Treatment Operations . Lithotomy . Lateral Operation . Cutting on a Straight Staff In Children Anatomical Peculiarities . Difficulties and Accidents In Adults . In Children After-treatment Consequences . Causes of Death, and Results . Recurrence of Stone Median Lithotomy . The Old Marian Operation . Allarton's Operation . Compared with Lateral Operation Results . XXXIX PAGH and Cal- 1027 1027 1027 1027 1027 1027 1027 1028 1029 1029 1029 1029 1029 1029 1030 1030 1030 1031 1031 1034 1034 1035 1036 , 1036 . 1036 . 1037 1044 . 1046 . 1046 . 1048 . 1048 . 1048 . 1052 . 1052 . 1053 . 1054 . 1055 . 1055 . 1055 . 1056 . 1056 xl CONTENTS. Injuries and Diseases of the Bladder—continued. Rectangular Staff Operation Comparative estimate of Bilateral Lithotomy Results .... Medio-bilateral Operation . Quadrilateral Section of Prostate Recto-vesical Operation . Comparative estimate of Results .... Supra-Pubic—Hypo-gastric, or High Operation Compared with Lateral Operation Results Lithotrity After-treatment Difficulties and Dangers Results, and as compared with Lithotomy Selection of Lithotomy, or Lithotrity Conditions determining Selection Recurrence of Stone Treatment Calculus in the Female Symptoms Treatment Operations Dilatation of Urethra Dilatation, with partial slitting up Double incision Lithotrity . Lithotomy. Urethral Direct. Vagino-vesical Supra-pubic Solution of Stone in Bladder Electrolysis . 1056 1056 1056 1057 1057 1057 1057 1057 1057 1057 1057 1058 1058 1063 1064 1065 1065 1065 1068 1068 1068 1069 1069 1069 1069 1069 1070 1070 1070 1070 1070 1070 1071 1071 1071 Chapter LVllI.—Diseases of the Bladder. Cystitis—acute .... Chronic ..... Tumours .... Fibrous—Warty—Polypoid Villous, or Vascular Cancer . Tubercle 1072 1073 1074 1074 1075 1075 1076 CONTENTS. xli Diseases of the Bladder—continued Haematuria .... Causes .... Treatment Malformations Absence, with communications of Ureters Rectal, Vaginal . Two or more Bladders Extroversion of Bladder . Operations Wood's Operation After-treatment . Results Functional Morbid Conditions Irritability of the Bladder Spasm ..... Neuralgia .... Paralysis .... Atony, from over-distension Frequent Micturition Incontinence of Urine Engorgement and Overflow Retention of Urine . Chapter LIX.—Diseases of the Prostate Inflammation—Prostatitis Abscess . . • Chronic Enlargement Atrophy Cancer Cysts . Tubercle Prostatic Calculus -Urethral, Chapter LX.—Diseases of the Urethra. Inflammation—Urethritis Gonorrhoea—Blennorrhagia Gleet .... Complications . Consequences Gonorrhoea in the Female . Stricture . Organic or Permanent Stricture Situation .... [Symptoms .... xlii CONTENTS. PAGE Diseases of the Urethra—continued. Varieties ...... . 1105 Causes ...... . 1107 Consequences and Terminations . . 1108 Treatment . . 1109 Gradual Dilatation . • . 1109 Difficulties and Accidents . 1111 Immediate and Forcible Dilatation ar Rupture 1112 Results . . . . . . 1113 Caustics . . 1114 Division of Stricture . 1114 Internal Urethrotomy . 1114 Results . . 1115 External Urethrotomy . 1115 Perinaeal Section . 1115 Results . . 1116 Spasmodic Stricture . . . . . 1117 Inflammatory Stricture . . . . . 1118 Tumours in Urethra . . 1118 Urethral Calculus...... . 1119 Retention of Urine . . 1120 Causes ....... . 1120 Consequences ...... . 1120 Treatment ...... . 1120 Catheterism ... . 1120 Incision of Urethra . . . . . 1121 Puncture of Bladder through Rectum. . 1121 Above Pubes . 1122 Through Symphysis Pubis . . 1122 Extravasation of Urine.... .1123 Rupture of Bladder . 1124 Urinary Abscess ..... . 1124 Urinary Fistula ..... . 1125 Varieties ..... . 1125 Urethro-plastic Operations . 1126 Urinary-Vaginal, and Uterine Fistula . 1127 Operations ..... . 1127 Chapter LXI.—Injuries and Diseases of Peni s. Injuries ...... . 1129 Wounds, and Laceration . . 1129 Haemorrhage ..... . 1129 Wound of Urethra .... . 1129 Diseases ...... . 1130 Balanitis and Posthitis . 1130 CONTEXTS . xliii ries and Diseases of Penis—conti Phymosis . PAGB fiued. . 1131 Congenital Circumcision . 1131 . 1132 Paraphymosis Gangrene of Prepuce Hypertrophy of Prepuce Warts .... . 1132 . 1133 . 1133 . 1133 Cancer of Penis . 1133 Scirrhus, and Epithelial Amputation of Penis Tumours—non-malignant Malformations . 1134 . 1134 . 1135 . 1135 Deficiency of Urethra Hypospadias Epispadias Absence of Urethra . 1135 . 1135 . 1135 . 1135 Scrotum, Testis, and Chapter LXII.—Diseases of the Cord. Diseases of Scrotum Inflammatory GMema Anasarca OZdema in New-born Infants Elephantiasis or Hypertrophy Excision, and Results Tumours • Fibrous Tumour Epithelial or Soot-Cancer . Diseases of Testis and Cord Hydrocele . Hydrocele of Tunica Vaginalis Varieties of Hydrocele Congenital Hydrocele Encysted Hydrocele . Hydrocele of Spermatic Cord Haematocele . Hematocele of Tunica Vaginalis Encysted Haematocele of the Testis or Varicocele Orchitis, and Epididymitis Chronic Enlargement Syphilitic Sarcocele Scrofulous Sarcocele Cord 1136 1136 1136 1136 1136 1137 1137 1137 1137 1138 1138 1139 1140 1143 1143 1144 1144 1145 1146 1146 1149 1151 1151 1152 xliv CONTENTS. Diseases of the Scrotum, Testis, and Cord—continued Abscess in Testicle Hernia Testis Tumours . .... Cystic Tumour Varieties Fibrous Tumour Cartilaginous Tumour—Enchondroma Cancer .... Encephaloid Scirrhus Castration, and Results Atrophy of Testicle Functional Disorders . Spermatorrhoea Impotence . . . ■ . Congenital Neuralgia of Testicle Malposition of Testicle. Congenital Diseases of Retained Testicle . Mis-descent of Testicle Inversion of Undescended Testicle Diseases of Vesiculae Seminales 1153 1153 1153 1153 1154 1155 1155 1155 1155 1155 1157 1158 1158 1158 1161 1161 1162 1162 1163 1163 1163 1163 Chapter LXIII.—Diseases of Female Genital Organs. External Organs .... Wounds of Vulva, or of Vagina Laceration of Perinaeum . Foreign Bodies in Vagina Diseases—Hypertrophy of Labia, or of Clitoris Condylomata or Verrucae Abscess of Labium Cystic Tumours Epithelial Cancer Rodent Ulcer Erectile Tumour Closure of Labiae, or of Vagina Imperforate Hymen Rectal and Vaginal Fistulae Prolapsus Vaginae Tumours Uterus ..... Displacements Prolapsus and Procidentia 1164 1164 1164 1166 1166 1166 1167 1167 1167 1167 1167 1168 1168 1169 1169 1169 1169 1169 1169 CONTENTS. Diseases of Female Genital Organs—continued Tumours .... Fibrous .... Polypi .... Cancer .... Absence of Uterus, and Ovaries Ovaries ..... Tumours .... Fibrous. Cancerous Cystic, and Ovarian Dropsy Treatment Tapping Obliteration by Injection Ovariotomy Conditions for Operation Operation After-treatment Results xlv PAGB 1170 1170 1172 1173 1174 1174 1174 1174 1174 1176 1176 1176 1177 1177 1179 1181 1181 ERRATA. Page xix. of Contents, line 10, for " Surgical," read "Lingual Artery." „ 176, line 30, for " suspicions," read " suspicious." „ 207, line 17, for " sequichloride," read " sesquichloride." „ 531, line 7, for " ends," read " end." „ 1056, line 8, for " muscles," read " vessels." THE SCIENCE AND PRACTICE SURGERY. Surgery is that primary division of Medicine, which has for its object the cure or the relief of morbid conditions of the body, in a corresponding division of Pathology. But the line of separation is arbitrary, conven- tional, and indefinite. Firstly, as to the nature of the morbid conditions, or Surgical Patho- logy. All injuries, malformations, and deformities, congenital and acquired, and all diseases affecting external parts, are usually allotted to Surgery. Secondly, in respect to the kind of Treatment, or the means of cure or relief. Surgery comprises all operations effected by instruments, manipu- lative procedures, and the employment of mechanical appliances; but it also has recourse to the administration of medicinal agents, and of hygienic measures. Surgical Pathology is both General and Special. General Surgical Pathology comprises the different forms of Injury and Disease which are common to all parts of the body; and these morbid conditions, illustrating the laws of Pathology, are the primary source of guidance in all surgical practice. As general forms of Injury—Wounds, Fractures, Dislocations, and Aneurisms, are naturally associated; and in virtue of the various laws whereby these lesions undergo Reparation, through processes which are more or less clearly referable to modifications of healthy Nutrition. But this department will be more conveniently considered in connexion with the particular Textures injured. Inflammation, Morbid Growths or Tumours, and Degenerations, may also be referred to modifications of Nutrition'; namely, to Accelerated, to Reproductive, and to Declining Nutrition. Certain Blood-diseases, Contagious diseases, and general dis- eases of the Nervous System, further illustrate the laws of Pathology and ^Special Surgical Pathology may be subdivided into injuries and diseases of the Textures and Textural Systems—e.g., the Skin and the Vascular System, and those which, with malformations, pertain to Organs and Herons—e.g., the Organs of Special Sense, and of Reproduction. The latter subdivision, as a mode of classification, makes no pretension to any scientific distinctions; it is simply an anatomical or a topographical arrangement of morbid conditions. 2 SCIENCE ASD PRACTICE OF SURGERY. The pathology of injuries and diseases, taken individually, embraces : (1) the particular structural condition presented, its signs and symptoms, and its diagnosis or detection and discrimination from other conditions; (2) its cause or causes, or etiology, and the effects of the morbid con- dition itself as a cause; (3) its course, terminations, and consequences, and the prognosis or foreknowledge of these events. The treatment in any case may be operative, or medicinal, or both. If in addition to the laws of Pathology, the guiding elements be selected in describing each form of Injury and Disease, and general Principles be established which shall govern its diagnosis, etiology, prog- nosis, and treatment, the whole of this guiding knowledge will constitute the Science of Surgery. The Principles here alluded to, form the design of my " Principles of Surgery"; and references, for the convenience of those who have that work, are made thereto, in the course of this volume. Such references are denoted by P., with the page, in brackets; as thus, [P. p. ]. But the two works are quite independently complete, each of the other. Regarded as an Art, Surgery may, like most other Arts, be practised in either of two ways: Empirically, by experience alone, or as a Scientific Art, by the guidance of the Science pertaining to it. In other words, there may be an empirical, or a scientific practice of diagnosis, etiological investigation, prognosis, and treatment; according as these branches of inquiry have, or have not, a dependence on guiding pathological know- ledge and principles. The Practice of Surgery, as a Scientific Art, might, in a restricted sense, have regard only to treatment, and this has been ex- clusively or principally its signification—Rules of Treatment having been designated the Principles of Surgery; but in its more extended meaning, the Art would also have reference to the application of Principles in the other, and preparatory, branches of inquiry. The relative importance of these three aspects of inquiry respecting morbid conditions, as to their nature, causes, courses and terminations, and of the whole of this pathological knowledge in relation to treatment, may be briefly estimated as follows. 1. Diagnosis is primarily necessary, in order to discover the particular structural condition, situation, and extent of the injury or disease, when capable of being so defined, and its distinction from other conditions. To make this discovery, the concomitant effects of the morbid con- dition are taken as Signs or Symptoms of its existence. The relative value of such evidence will depend upon, and vary with, its more or less con- stant and exclusive conjunction with the morbid condition. Accordingly, a Symptom, or as the etymological meaning of this term would express, a coincidence or co-occurrence, is less characteristic and distinctive than a Sign, the latter being that by which anything is known or recognised. Any sign peculiar to a morbid condition is named pathognomonic. The earliest and most exact source of diagnosis is Pathological Anatomy, as directly manifesting during life the essential nature of the morbid condition, by the physical, the structural, or the chemical changes which the part affected undergoes. Diagnosis may be corroborated by Pathology—i.e., the functional disturbances accompanying the particular disease or injury; also by connecting the morbid condition with its external cause, and by the characteristic effects of the therapeutic measures employed. For example, the fact of an individual having been exposed to INTRODUCTION. 3 malaria, is evidence presumptive that he may have ague; whilst the fact of his disease disappearing by the administration of quinine alone, is, among other evidence, corroborative of that disease being ague. But the diagnostic value of all such circumstantial evidence is regulated by its more or less constant and exclusive association with the disease or injury which is sought to be identified. Viewed in this light, the evidence of Pathology—functional distur- bances—of external causes, and the effects of therapeutic measures, possess different degrees of diagnostic value ; but the assurances derived from all these resources are, at the best, equivocal, and therefore mis- guiding. Here it is that Pathological Anatomy, applied during fife— Clinical Pathological Anatomy—comes to our aid. By an appeal to the " physical" properties of organs and textures, as discovered during life, we can partly corroborate or rectify our inter- pretation of mere functional symptoms. By the "structural" character of morbid products and secretions dis- charged from the natural passages—as the mouth, oesophagus, stomach, and intestines; the lungs, urinary bladder, kidneys, uterus, and vagina; those also which are externally yielded by or through the skin, or pro- cured by puncture, as from tumours ; possibly, in some cases, by " chemical" analysis of some such materials; we gain direct insight into, and evidence respecting, the structural conditions of most internal organs and of morbid products issuing from them. Such application of Pathological Anatomy, therefore, directly indicates the exact structural condition, the situation, and even the extent, of the disease; and by virtue of this qualification, as a method of diagnosis, is more trustworthy than the evidence of Pathology, or any other collateral testimony. The superiority of physical diagnosis, by virtue of the earliness with which the physical characters of a disease become obvious during life, is impaired by its inferiority in respect of exactitude, as compared with structural diagnosis. Duly weighing all these considerations, we arrive at this conclusion— that it is only by careful and repeated clinical observation of the '' physi- cal," the "structural," and, if possible, the " chemical" conditions— which taken collect/rely, are the constant signs of disease ; by a similar observation of any collateral" circumstances of evidence—i.e., alterations of function ; precurrence of external causes, and the effects of therapeutic measures; and by connecting all this evidence during life, with certain pathologico-anatomical alterations, as demonstrated ,by the scalpel, the. microscope, and possibly, by chemical analysis after death—that we can rationally hope to establish the earliest and most exact diagnosis. This connexion, oft-recurring, at length begets self-confidence; so that with the accumulation of such experience our diagnosis, although deter- mined during life, and therefore by evidence not infallible, yet having been repeatedly verified by post-mortem examination, now supplies a pro- portionately sure basis for Therapeutics. 2. Etiology comprises the knowledge of causes, and their operation, in the production of injury or disease. Such causes may be external to the body, as external violence in the production of injury, or exposure to cold in inducing disease; or, they may be internal, by the excess, defi- ciency, or perversion, of structure and function. Both classes of causes may be either predisposing, or immediate and exciting, in their opera- 4 SCIENCE AND PRACTICE OF SURGERY. tion. Sometimes, the former occurs after the latter mode of causation, as when an individual undergoes fatigue or privation, after exposure to an infectious poison. Then, that weakening of the system cannot be said to predispose, but it is aptly named the determining cause. An innate power of resisting the supervention of morbid conditions, explains why the same cause does not invariably produce its reputed effect in different individuals, or in the same individual, at different periods , of life ; this uncertainty being due to different degrees of resisting power. But the influence of habitual toleration will also much affect the operation of causes, whether external or internal. Either kind of cause may be self-sufficient, but both kinds frequently co-operate, or operate in succession ; the internal cause more commonly predisposing, the external, when sufficiently aided thereby, immediately inducing disease, or, occasionally, injury. Thus, a fall which does not produce a hernial protrusion in one case, immediately does so in another, owing to weakness of the abdominal wall at the seat of rupture, as the structural predisposing condition to this lesion ; and a posture which does not cause an apoplectic seizure in one case, immediately does so in another, owing to the blood-vessels of the brain having become brittle from calcareous degeneration. Causes are also distinguished as local and constitutional. The former term requires no definition ; the latter signifies such conditions of disease as have a systemic character, and a correspondingly widespread influence, in the production of local manifestations. Such are principally diseases of the blood, of the nervous system, or of nutrition. Local causes may give rise to constitutional diseases; and conversely, any constitutional cause must give rise to, and be manifested by, some local affection or affections. Thus we speak often of the constitutional origin of local disease, a general and most important doctrine of etiology, originally taught by Abernethy. The detection of internal causes, whether local or constitutional, may be regarded as an extension of diagnosis, and consequently pertains chiefly to Clinical Pathological Anatomy; but the operation of these causes, through functional disturbances, comprises the study of Pathology. 3. Prognosis, or foreknowledge of the course and terminations of in- juries and diseases, implies their continued functional disturbances, and as such an enlarged study of Pathology. 4. Treatment derives its Indications from each of the three foregoing heads of inquiry respecting morbid conditions. Diagnosis fixes the essential nature of the morbid condition, and thus not unfrequently indicates the requisite remedial measures, particularly as to surgical operations, ma- nipulative procedures, and mechanical appliances; etiology supplies the knowledge of causes, which, if they be still in operation, must be re- moved ; and prognosis determines the remaining indications of treatment. A considerable portion of surgical treatment yet remains empirical • but it is now generally felt and acknowledged to be proportionately aimless, and as often therefore unsuccessful. Such treatment of injury or disease is like trying to hit a mark blindfolded. It can, indeed, only be regarded as a temporary resource, accepted by the Practitioner under the pressure of his natural anxiety to relieve human suffering in any possible way, but as often little better than nothing until enlightened by Pathology. As thus directed, however, Treatment acquires three primary Indica- INTRODUCTION. 5 tions of the highest importance. In proportion as the natural course of any morbid condition is towards an unfavourable issue, the Surgeon thence discovers the earliest occasion for interference, and the unfavourable con- ditions to be removed; while, in proportion as the Natural Course is towards recovery, it indicates the least amount as well as the kind of surgical assistance requisite, from time to time, to conduct the case to this happy issue. These three Indications of Treatment may be recognised more especially in respect to the general forms of Injury and Disease. Treatment in accordance with the natural course of morbid conditions towards recovery, is evidently responsive to the requirements of a self- restorative or reparative power, which is inborn and inherent in the living body. Hence, I have long since designated such remedial treat- ment, " Conservative," whether in Surgery or Medicine, as denoting its preservative power, the timeliness and moderation of its remedial assis- tance. (" Medical Times and Gazette," 1864-65.) The term "Con- servative Surgery," as originally understood, when introduced by Sir W. Fergusson in 1852 ("Medical Times and Gazette"), was restricted to operations for the preservation of some part of the body, which would otherwise have been inconsiderately and unnecessarily sacrificed. The performance of some operation of removal having become necessary, in consequence of an incurably diseased or injured state of a part; a lesser and limited operation, the extirpation of that part alone, may then be sufficient, instead of an operation involving also any portion of the sound organism. Of two, or more, practicable operations of removal, this consideration of anatomical preservation, may thus guide the Sur- geon's choice. For example, excision of an incurable diseased joint, may be performed, instead of amputation of the limb. Thus, observes Sir W. Fergusson, a compromise may be made, whereby the original constitution and frame, as from the Maker's hand, may be kept, as nearly as possible, in its normal condition. Pathology in Surgical Operations.—In the design and performance of Surgical Operations, the Guidance of Pathology, supplements and com- pletes that of purely healthy Anatomy; this conjunction giving rise to what I have designated "Pathological Operative Surgery." (Ibid., 1865.) The contrast between the Continental and the English Schools of Surgery, mainly turns on this more intimate incorporation of Pathology with Operative Surgery. Thus, in France, we find that it was advo- cated : by Sabatier (1832), Lisfranc (1845), Vidal (de Cassis) (1846), Sc'dillot (1853), Malgaigne (1861), Chassaignac (1861), Velpeau, and Nekton. In Germany, the same position is urged by Chelius, Luihart, Dieffenbach, and Langenbeck. In Italy, by Scarpa (1809). America also has responded to this spirit of progress, as testified by Mott, Physick, and Gross. In this country, its influence has been more slowly felt. For, although in Scotland, so long since as 1801, John Bell overthrew the Anatomy of Surgery, as then taught in the schools, his denunciation was as "the voice of one crying in the wilderness;" and in England the purely Anatomical Operative Surgery of his brother, Sir Charles Bell, long prevailed. Nearly fifty years afterwards (1846) Liston noticed the influence of Pathological Anatomy on the "Abridgment" of Operative Surgery; by Sir William Fergusson, its occasional applicability in surgical operations was acknowledged in the third edition of his Practical Surgery (1S52V and Skey recognised it in like manner in the second edition of his Operative Surgery (1858). In March, 1864,1 brought prominently forward 6 SCIENCE AND PRACTICE OF SURGERY. in my "Principles of Surgery," the Guidance of Pathology in Surgical Operations, as a general Principle; positively true, in the great majority of operations, where the seats of operation and of disease or injury are identical; negatively true, in other operations, where the object is to operate clear of the disease and amid healthy tissues. I followed up this position at the dates already referred to; and more recently, Mr. Hancock endorsed the principle, as regards Surgical Operations on the foot, in his Lectures at the Royal College of Surgeons, 1866. Having exposed at some length "the very grave error," with reference to diseases of the foot, of " reducing conservative to mere anatomical Surgery;" he ob- serves—" Experience has proved that we may do much more good by regulating our operative proceedings by the amount and character of the mischief; and hence I would venture, as suggested by Mr. Gant, to designate the Surgery of the foot, ' Pathological Surgery of the foot,' as being more comprehensive, as imposing this law upon us more strongly than does the term 'Conservative Surgery,' and, at the same time, implying the regulations which should govern us in our operative procedures." Having thus traced the development of Modern Operative Surgery, it will be most advantageous in this introductory portion of the work, to show how Surgical Anatomy, properly so called, is modified throughout by constant association with pathological conditions, in the performance of any operation. Such an association will tend to correct the purely Anatomical impressions of the Student, and to safely guide the operating Surgeon. It is only under the circumstances of disease or injury and life com- bined, in other words, Pathology, in conjunction with Anatomy, that the operating surgeon interferes. He is never called upon to touch the body in its healthy anatomical conditions. True, certain Operations are ap- parent exceptions to this otherwise unexceptional law. It may be, as I have said, that the seats of operation and of disease or injury are not identical; that our operation is somewhat removed from the diseased or injured locality. Such are amputations, and the ligature of arteries for aneurism. But even under these circumstances, pathological anatomy can alone determine whether or not we operate clear of the disease and amid healthy tissues;—whether, for example, the bone and soft parts left after amputation are healthy, and whether we cast our ligature around a healthy portion of artery. This negative application of pathological ana- tomy is obviously of the highest importance in respect to the successful results of surgical operations. On all other occasions, the physical properties and relations of parts disclosed during an operation are then so changed by disease as some- times scarcely to admit of recognition; and thus it is that anatomy plus certain pathological alterations, or the pathologico-anatomical conditions of the body, are those with which the operating surgeon is concerned. Guided by this a priori principle, we can predicate those pathological conditions which from their nature must chiefly influence the performance of surgical operations ;—alterations of certain physical properties, more especially of colour, consistence, and elasticity; also modifications of shape and size, with those affecting the situation, position, and relation of parts; such peculiarities altogether change the scene with which the mere anatomist is familiar. Nor are these the only circumstances that overshadow the appearances to which he is accustomed. Whoever has observed the arm of a dead sub- INTRODUCTION. 7 ject as it lay extended over the side of a dissecting-table, must have been struck with the well-marked bicipital depression, especially visible on a thin subject. If injected, the brachial artery can almost be distinguished as a prominent line throughout its course. Apparently, a single incision would bring one down upon the vessel, and so it does. The skin, gluey and adhesive, hangs upon the knife; nor does the incision gape; the artery is soon exposed, not being overlaid by the contracted biceps, and only, perhaps, obscured by the turgid vein on its inner side. Contrast all this with the same proceeding during life. We observe no such well- defined groove to guide our incision; the skin yields before the knife with a crimp and elastic resistance; the wound gapes; the swollen and vibratile belly of the biceps muscle, especially if amply developed, over- lays the artery, while the vein, perhaps not so turgid, immediately con- ceals it. More or less haemorrhage Avill also further obscure the vessel, which can only be recognised by its beautiful fawn-colour and its pulsating under the finger. I have purposely excluded the brachial plexus of nerves from this sketch, in order more clearly to contrast the dead with the living. This illustration will apply, mutatis mutandis, to operations for the ligature of other arteries ; and the experience of every practical Surgeon will supply him with the more extended application of the same principle during all other surgical operations. We must, therefore, acknowledge also the guidance of living (not merely functional) conditions during the performance of surgical opera- tions. The condition of life modifies certain physical appearances, and chiefly those affected by pathological anatomy. Thus, the colour, con- sistence, elasticity, and even the size and shape of the various parts of the body, their situation, position, and relation to contiguous parts, are presented to the Surgeon, when modified by the twofold conditions of Disease and Life combined. These together may be termed Pathology, and not Pathological Anatomy, which represents only dead structural disease. Pathology,— conjoined with Anatomy,—is, therefore, our guide during surgical opera- tions. In proportion as we are familiar with pathological conditions, by so much are wre enabled to foresee, and to provide for, the peculiar appearances and conditions which the knife discloses, and to recognise them as they are successively presented in surgical operations. Guided by this anticipatory knowledge, our operations are no longer discoveries made by dissection, but planned and methodical proceedings, conducted on known principles—in fact, an Art, based on the science of Anatomy supplemented by Pathology. When a pupil of the late Robert Liston, I frequently witnessed, and for many years observed with care, the operations of that illustrious surgeon; and I venture to affirm, that if one circumstance more par- ticularly contributed to the ease and elegance of his operations, it was the suitable (artistic) method on which he planned and conducted them. If I ini"iit use the expression, there was a kind of slow-quickness about all he did__the former quality indicating the method he pursued, the latter resulting from its sufficiency and skilful application. The twofold Principle I have advanced might be further elucidated by tracing the combined influence of disease and life on the scenes of the chief Operations of Surgery. A series of such illustrations are given in my work on " Principles," and Pathology, with Anatomy, will be found 8- SCIENCE AND PRACTICE OF SURGERY. to govern the design and guide the performance of these and other opera- tions generally, as described in the course of this work. Without the knowledge of Anatomy, attired in the garb of disease and life, neither safety nor success can be attained in the planning and performance of Surgical operations. " The operator,—I would say without this knowledge, is seen agitated, miserable, trembling, hesitating in the midst of difficulties, turning round to his friends for that support which should come from within, feeling in the wound for things which he does not understand; holding consultations amid the cries of the patient (before the days of chloroform), or even retiring to consult about his case, while he lies bleeding, in great pain and awful expectation." But, no less important in Operative Surgery, is the knowledge, chiefly Pathological, to which I would next direct attention, as mainly determining the success of operations. Conditions Favourable and Unfavourable for Operation.—The selection of cases fitted for Operation should always most seriously engage the Surgeon's consideration. The Conditions Unfavourable for any Surgical procedure being known, all other conditions may be presumed to be favourable. Unfavourable conditions comprise : (1) certain states of the Patient's Health, constitutional, and local in regard to the seat of disease or injury ; (2) the Hygienic conditions by which he is surrounded. Constitutional conditions unfavourable for Operation, relate both to the mind and body. Persons who are naturally of an irritable and anxious, or of a despond- ing, mind, cannot sustain a surgical operation so well as those of a tranquil and cheerful disposition. This rule holds good also in the case of persons who, from temporary circumstances, may be mentally affected in like manner. And especially unfavourable, is any despondency respecting the issue of the operation itself. This adverse influence affecting the Patient's bodily health, before and after the operation, will be alone sufficient to undermine the result of any skill on the part of the Surgeon. On the other hand, the sustaining influence of hope is well exhibited by the fatal effect produced whc-n it is suddenly withdrawn. Sir A. Cooper tells the story in his Lectures of a poor countryman in Guy's Hospital, who, lying in bed previous to a capital operation, was asked by a student what part of the country he came from ; Cornwall he replied. Then said his interro- gator,—you will never see Cornwall again. Nor did he ; the man never rallied. An instance of such heartless or thoughtless indiscretion, suggests the kind of address and tact, animated by honest sympathy, with which the true Surgeon will manage his patient's mental disposition, ever fairly support- ing hope as the well-spring of life. Conditions of bodily health, of a constitutional character, unfavourable for Operation, are numerous. They relate to all the organs of the body, and vary in importance according to the physiological agency of the organs in maintaining life. Thus, the nervous system, the heart, lungs, digestive organs, and excretory organs, especially the kidneys and skin, have severally to be considered, and from a twofold point of view. Firstly, organic conditions must be considered, as affecting the general health, and thence the life, of the individual, when subjected to any particular surgical operation; and, secondly, they should be regarded in relation to reparation, or the reserve-power of nutrition requisite INTRODUCTION. 9 after any operation of magnitude, and which necessarily also entails an ordeal of some duration for the system to undergo, before the health can possibly be re-established. The state of the nervous system is a primary consideration. When itself naturally irritable, or when in an irritable state for the time being, this condition is peculiarly unfavourable for surgical operation. It seems to be associated with a weak circulation, and the patient is apt to sink soon after any severe surgical procedure. But the judicious adminis- tration of opium with wine, brandy, or other stimulants, will often succeed in preparing the patient for operation, and carry him or her through the critical period subsequently. Chloroform, besides preventing pain, has a specially beneficial influence in irritable nervous persons, subjected to operation for surgical disease, or when the circulation is depressed by the shock of injury. Certain blood-diseases prohibit any surgical operation, otherwise than one of immediate necessity for the preservation of life. Thus, any operation of choice should be postponed when the patient is labouring under erysipelas or pyaemia. Other diseases have not a fatal tendency, yet their existence is adverse to the successful result of an operation. Such are scrofula, and the contamination of the system by malignant disease. In the latter case, an operation will be almost surely followed by a return of the disease, in situ, or its development in some distant part. Heart-disease, and particularly fatty degeneration of this organ, should make the Surgeon consider the necessity or the advantage of any operation attended with much loss of blood or shock to the nervous system. Con- sequently, when the pulse is habitually feeble, irregular, and perhaps slow, the patient breathless on slight exertion, and marked with the arcus senilis; these symptoms co-existing, almost surely indicate fatty degene- ration of the heart, and should warn the Surgeon that he has a bad subject to deal with. ZwH<7-disease does not seem to have so important a relation to Surgical Operations. This may, perhaps, be explained by the fact that after any severe operation, the patient being confined to bed, there is no special demand on the function of the lungs as the organs of respiration. As double organs also, one may be more or less diseased and incapacitated, and the other fulfil a double or compensatory function, and especially in the case of old-standing disease. Phthisis is an exceptionally unfavour- able condition, and particularly if this disease be in an active state or in an advanced stage. The operation for fistula in ano, a disease often co- existing, should not be performed under these circumstances. The Digestive-organs play a most important part with regard to the result of surgical operations, and disorders or derangements of these organs demand the most careful consideration. Obviously this is due to the necessity arising after any operation of magnitude, for an extra supply of nutritive material to meet the demands of the reparative process, a supply which implies an active state of the digestive organs incompatible with any kind of indigestion. Irritable dyspepsia, and hepatic derangement, terms not very definite, but sufficiently familiar in practice, represent the conditions which are most adverse to surgical procedures. The kidneys and skin, as excretory organs, have a grand relation to surgical operations by purifying the blood of noxious matter, the reten- tion of which would inevitably spoil the material requisite for reparation. 10 SCIENCE AND PRACTICE OF SURGERY. Disease of the kidneys, in the various forms of degeneration, accompanied with albuminous urine, and the retention of urea in the blood, constitutes the most unpropitious condition under which a patient can be subjected to operation. The wound is apt to undergo diffuse inflammation and sloughing, while the patient sinks rapidly from the exhaustion of blood- poisoning. This seems to arise from the local products of inflammation, thus induced, becoming absorbed, and accumulating in the blood, soon overwhelm the system beyond the endurance of life, when already oppressed by the uraemic poisoning. In this condition also, both kidneys are diseased, so that there is no chance of any relief by one organ compensating for the functional deficiency of the other, as in the case, sometimes, of the lungs. The state of the skin must also be taken into consideration before undertaking any operation. A cool, moist, soft, perspiring skin is no less conducive to success, than a free secretion of healthy urine. Chronic diseases of the skin, such as lepra or psoriasis, involving a large extent of the cutaneous surface, had better be treated before proceeding to any surgical operation which can be postponed. Pregnancy does not prohibit any surgical operation, excepting in so far as this state may thereby be itself affected. In the case of a lady advanced in pregnancy, I have removed a large slough from the abdomi- nal wall by incision, without disturbing the course of pregnancy; but, on another occasion, in the same person, the removal of necrosed bone from the scapula, under the influence of chloroform, was followed by a mis- carriage the next day. Obesity is said to be, in itself, a condition very unfavourable for opera- tion, owing to the feeble circulation in such subjects. Old age naturally renders an individual less able to sustain the shock of an operation, and the loss of blood; subsequently also there is less power to pull through to recovery. Idiosyncrasy, or some unknown constitutional condition peculiar to the individual, may prove singularly prejudicial to the success of even a trifling operation. Thus, in one case, after removing a small fatty tumour from the abdominal wall, on the following day the adjoining integument presented a sphacelated black patch, with an abundant, thin suppurative discharge from between the lips of the incision. Local conditions unfavourable for operation relate to any diseased state of the part itself, which will tend to produce an unsuccessful result. Thus, acute inflammation of a joint, for example, would be adverse to excision ; and a sloughing condition of the parts involved in the flaps of an amputation, would defeat the purpose of this operation. Cancer, or disease of a malignant nature, should never be removed, unless the whole disease can be freely extirpated. Any portion beyond the reach of opera- tion will necessarily cause a return of the disease, in situ ; an important consideration, in addition to the question of probability as to the develop- ment of cancer in some distant part. Hygienic Conditions.—Besides the state of health, constitutional and local, by ay Inch a patient may be in an unfavourable condition for opera- tion ; the hygienic circumstances in which he is placed, both before and afterwards, will much affect the probability of success. Adverse hygienic conditions comprise chiefly: Defective Diet, in quality, quantity, or in both respects; overcrowding of the sick and wounded, especially those having open and suppurating wounds, or Deficient Ventilation ; Exposure INTRODUCTION. 11 to Contagious or Infectious matter, by dressings or inhalation, as in the propagation of Hospital gangrene and erysipelas. The minimum space allotted to each patient in the Surgical Wards of an Hospital should be 1500 cubic feet of air to each person. And this quantity must be accom- panied with change of air also, by proper ventilation. Preparation of Patient for Operation.—It is scarcely necessary to observe that, on the ground of personal liberty of the subject, and legal liability of the surgeon, the consent of the patient, and of his or her im- mediate relatives, should first be obtained before proceeding to any sur- gical operation. But this rule Avill as necessarily admit of exceptions, according to the mental capacity, or the age of the patient; the more or less urgent nature of the case proposed for operation. If the patient be sensible, of sound mind, and mature age; and he resolutely and persistently refuse to allow an operation of urgency to be performed; and if, moreoA'er, his determination be backed by that of an immediate relative, as his wife; the Surgeon will have no alternative but to give up the responsibility of the case. Thus, I have seen a man die from strangulated hernia, in spite of the earnest and repeated remon- strances of the Surgeon to him, and his Avife, as the strangulation pro- ceeded to a fatal termination. On the other hand, if the patient be in- sensible, or imbecile, or in the case of a child or infant, and in the absence of immediate relatives or parents, the operation being an urgent one, the Surgeon will be free to act according to his own judgment. The preparation of the patient, mentally and bodily, will consist in inspiring him with cheerful hope, and in bringing his bodily health to a quiescent condition, especially observing that the actions of the digestive organs, and of the skin and kidneys, are healthy, when time can be allowed for any such preparation. This tranquil, even state of mind and body, is that best fitted for operation. But, when no time can be permitted for any constitutional preparation, as after most severe injuries, the patient must be at once submitted to operation. Arrangements for Operation.-—The arrangements requisite for the effi- cient and convenient performance of surgical operations, relate to the Room, the Operating-table, Instruments, Avith other Appliances, and Assistants. The Room, of convenient size, should admit a good light, an over-head or skylight being very desirable for most operations; it must be ade- quately warmed in cold weather, or for the performance of operations wherein the abdomen is opened and the viscera exposed, as in operating for strangulated hernia and in ovariotomy ; but there should also be the means of free ventilation or change of air about the patient, when under the influence of chloroform. Besides the requisites of light, temperature, and air, an ample supply of Avater, Avarm and cold, must be at hand. The Operating-table must be strong, and firm-standing (not moving on castors), of convenient height, and Avidth only of the body, covered with blankets overlaid Avith india-rubber sheeting, and provided with pillows. The tables constructed for operation, as used in Hospitals, are fitted with a mechanism for raising the head and shoulders to any requisite height; and flaps are provided for leaving the legs unsupported, as for amputa- tion, or when the nates are placed so as to rest over the end of the table, as for lithotomy, and other perineal operations. A low, firm stool will be a requisite accompaniment for these operations, to seat the operator in cutting for stone, or an assistant in holding the leg for amputation. 12 SCIENCE AND PRACTICE OF SURGERY. An Operating-chair, instead of a table, is necessary for cases wherem the patient is seated ; as in operations about the face, the extraction of nasal polypi, for cleft-palate, or the removal of either jaw ; also, for other operations, as amputation at the shoulder-joint, and tapping the abdomen. The chair itself, firm-standing, and high-backed to support the head, much resembles a dentist's chair. These arrangements respect- ing the room and table should be seen to by the Surgeon himself, when not regularly provided as in a Hospital; but the remaining provisions, as to instruments and assistants, must always be personally super- intended. The Instruments necessary should be well selected Avith regard to the nature and possible complications of the operation; and for convenience, they should be arranged on a small table or tray, in the order in Avhich they are wanted, and placed near the Surgeon, so that he can help him- self to any instrument he may require, or have it handed to him im- mediately by an instrument-assistant. The collection of instruments, however few, had better be covered with a towel, to conceal them from the eye of the patient Avhen brought into the room. Sponges, of various sizes, clean and compressible, with lint and plaster, will always be pro- vided by any well-trained nurse; but here again, the Surgeon had better see that these appliances are at hand. Any splint or other accessory requisite for application after operation, and previously prepared by the nurse or an assistant, should also be inspected. A tray containing saw- dust or sand may be placed on the floor so as to catch the blood; but this has a repulsive appearance, and it is more agreeably substituted by a piece of maroon-coloured oil-cloth under the table. The operator may be conveniently dressed, in an easy-fitting, long cut, alpaca coat, or dressing- goAvn. The Assistants should be in number sufficient, but not superfluous, and each should have an allotted duty to perform, orderly and silently. Thus, for a capital operation, as amputation, joint-excision, or lithotomy, four, or not less than three assistants, -will be required ; one, specially to administer chloroform ; then, in the first-named operation, another to com- mand the main artery; a third to hold the limb in position; and a fourth to take charge of the flaps, and ligature the vessels as they are seized by the Surgeon. A fifth assistant might hand the instruments; but they are often taken up most readily by the Surgeon from the table near to him. Anaesthetics.—The greatest gift of God to man, through Natural Science, is, perhaps, the discovery of means for the prevention or the abolition of bodily pain. This exemption approaches the realization of that blissful hereafter, one of the Divine promises of which is, that then " there shall be no more pain." Glimpses of the truth as now made known have appeared in various ages; but it was not until the year 1800 that Sir Humphry Davy, having himself experienced relief from pain while breathing nitrous oxide gas, suggested the possibility of employing the influence of this agent for the same purpose in surgical practice. After the lapse of nearly half a century, in 1844, the same idea occurred to Dr. Horace Wells, a dentist in Hartford, America, Avho underwent the extraction of a tooth without pain after inhaling the gas, and he administered it with the same effect to several of his patients; but, finding the practice uncertain, he soon abandoned it. About the same time, Dr. W. T. G. Morton of Boston, in INTRODUCTION. 13 America, who had previously been a partner with Wells, sought of his own accord, without it would appear receiving any suggestion from him, to discover an efficient anaesthetic ; and having experimented upon himself and the lower animals, he extracted a tooth painlessly from a patient, under the influence of sulphuric ether by inhalation; this event taking place on the 30th of September, 1846. He then publicly exhibited the efficacy of this agent at the Massachusetts General Hospital; and thence- forward anaesthesia in surgery became an established blessing to mankind. It was not long ere this invaluable discovery was recognised, and followed up by farther investigation in this country; Avhich resulted in the introduction of chloroform, and its employment instead of sulphuric ether. The latter agent is still extensively used as an anaesthetic in America; but in Europe, chloroform is now generally preferred to it. Disguised under the name "chloric ether," in Avhich it exists diluted Avith spirit of wine, this agent was employed by Dr. Morton in his first experiment upon himself; and it is a fact, not perhaps generally known, that it was also used in the same form, in preference to sulphuric ether, by Mr. Lawrence, at St. Bartholomew's Hospital, in the summer of 1847. Mr. Paget confirmed this fact by information communicated to Mr. Lister; to whose article on anaesthetics, in Holmes's Surgery, I am indebted for the particulars of the foregoing historical sketch, and for much which follows on this subject. It was in the autumn of 1847 that Dr. Simpson, who was engaged in a series of experiments with various narcotic vapours, employed for the first time the active principle of chloric ether, at the suggestion of Mr. Waldie, of the Apothecaries' Hall of Liverpool; and finding that pure chloroform had certain advantages over sulphuric ether, he zealously recommended it to the Profession, and it has since been generally used. The advantages alluded to in favour of chloroform are, that it is a more potent anaesthetic, its inhalation causes less bronchial irritation, its odour is more agreeable, it is less volatile, thereby rendering its administration more easy ; and lastly, the vapour of chloroform not being inflammable like that of ether, it is fitted for operations by artificial light. Chloroform.—This anaesthetic agent "will be briefly considered in regard to :—its physiological action ; the phenomena produced by inhala- tion; the question of its contra-indication in certain diseased conditions of the system ; the method of administration; death from chloroform; and the treatment of an over-dose. Physiological Action.—The action of chloroform on the functions of the nervous system is such as to render it exactly suitable for the pur- poses of surgical practice. Chloroform is a narcotic, and like most medicinal agents of this class, it produces temporary excitement, folloAved by suspension of the functions of the nervous centres; but it affects them not simultaneously, but in a certain order. The brain is the first to evince loss of poAver, in the failure of sensation, including consciousness, and voluntary motion; the spinal cord, or rather the whole cerebro-spinal axis secondly, soon loses the reflex function of involuntary excito-motion, so far as regards the voluntary muscles, Avhich lie perfectly relaxed and passive. This combined state of insensibility to pain, paralysis of muscular action, voluntary, and involuntary Avith regard to the voluntary muscles, presents a condition most favourable for the performance of surgical operations. On the other hand, the involuntary action of the muscles eno-ao-ed in respiration remains, and the action of the heart, as dependent 14 SCIENCE AND PRACTICE OF SURGERY. on the ganglia of the sympathetic nerve, continues. Thus then, while the whole physiological condition of the nervo-muscular system suits the convenience of the Surgeon, and the patient is rendered insensible to pain; those dependent functional actions are retained which are essential to life. Certain other important advantages attend the inactivity of the cerebro-spinal centre. The shock of injury, which Avould be increased by the additional violence of surgical operation, is diminished under the influence of chloroform; thence, the contractile power of the heart, as affected by the action of the brain and spinal cord upon the cardiac ganglia through the medium of the pneumogastric and sympathetic nerves, is unreduced by such violence, thus averting the tendency to cardiac syncope and death during operation; and lastly, in the absence of faintness, the vessels bleed freely, and by at once declaring those which require ligature, the liability of secondary hemorrhage is prevented. Moreover, the mental tranquillity secured before operation by the pros- pect of immunity from suffering, is a condition highly favourable to recovery afterwards. Phenomena or Symptoms produced by the action of chloroform.— After inhalation for a time, varying considerably in different individuals, but generally of longer duration in adults who have been accustomed to the free use of narcotics, and shortest in children, symptoms of excitement are manifested by various ejaculations, and by muscular rigidity and movements requiring some restraint; but this state is soon and suddenly succeeded by complete relaxation and insensibility, accompanied with deep heavy respiration. Or, without any previous stage of excitement, the patient may at once pass into a state of tranquil sleep. The sus- pension of reflex action is denoted by the absence of unconscious winking when the eye-ball is touched with the tip of the finger, as a stimulus; a state commonly regarded as insensibility of the conjunctiva. The heart's action, and pulse, at first quickened and more forcible than natural, subsides under the influence of chloroform, and becomes slow and feeble or scarcely perceptible. The respiration also becomes feeble and imperfect, and the blood proportionately venous; a state approaching or bordering on asphyxia. Snoring or stertorous breathing is soon induced, passing into complete obstruction to the entrance of air into the chest, although the respiratory movements of the thoracic walls still continue. Occasionally, without any premonitory stertor, the breathing becomes more or less suddenly obstructed, and a livid turgescence over- spreads the face. Death is imminent where inhalation is carried to this degree as regards either the circulation or respiration ; and whether as the result of administering a highly concentrated vapour, or of long continued inhalation. There are instances occasionally of persons who, from some peculiar idiosyncrasy of constitution, are incapable of being affected by chloroform ; they are proof against its anaesthetic influence. Thus, I have known four ounces of chloroform administered to a lady, by inhalation, without pro- ducing the slightest effect. Contra-indications to the employment of chloroform.—Certain con- stitutional conditions and organic diseases, are said to prohibit the use of chloroform, or to require extreme caution in its administration. The influence of shock has already been adverted to, in speaking of the physiological action of chloroform. Pain is not a stimulant but a depres- INTRODUCTION. 15 sant, and therefore the performance of an operation during the con- tinuance of shock, and without chloroform, would increase the collapse; and, moreover, as already explained, the influence of this agent protects the action of the heart from the tendency to cardiac syncope, resulting from the pain incident to an operation. Hence, operations may be safely performed, under the influence of chloroform, during the shock of injury ; thus overturning the old rule of postponing operation, amputation for example, until the patient has recovered from the state of collapse. The system may be at once relieved from the injurious presence of a mangled limb, or life preserved where it would be hopeless to Avait for returning consciousness. But, during shock, it is unnecessary to give chloroform to its full extent; but only so far as to benumb sensation in the incisions or painful part of the operation. Epileptic persons may be subjected to the influence of chloroform- inhalation, administered cautiously, however, considering their liability to suffer from congestion of the brain. Hysterical persons are said to be subject to laryngeal spasm, during inhalation. Disease of the Heart does not absolutely contra-indicate the adminis- tration of chloroform, but only that it be given with extreme caution ; watching the pulse especially, and the breathing. In fatty degeneration of the heart, the sedative influence of chloroform is liable to suddenly arrest the action of this organ with instant death. In valvular disease there is less danger. Disease of the Lungs is not specially obnoxious to inhalation. In phthisis, not far advanced, no difficulty arises; but with bronchial irrita- tion, troublesome cough is apt to be produced. Disease of the Kidneys, resulting in degeneration of these organs, and the retention of urea in the blood, is a condition decidedly unfavourable for the administration of chloroform. Congestion of the brain being superadded to the uraemic-poisoning, may induce epileptic convulsions, with lividity of the face, stertorous breathing, and coma. All Surgical Operations allow of the employment of chloroform, ex- cepting a few in which the assistance of the patient is required, and in operations attended Avith copious haemorrhage into the mouth. In some cases, hoAvever, pain may be prevented to a great extent, by giving chloroform during the earlier or more superficial parts of the operation. Age is no objection to the employment of chloroform; infants and octogenarians taking it Avith safety. Administration of Chloroform. — Prior to giving chloroform, the patient should be directed to omit taking food for four or five hours, as the presence of any food in the stomach is apt to cause troublesome vomit- ing during inhalation. The patient lying recumbent A\rith the head and shoulders just comfortably elevated on a pillow, he should not be allowed to raise himself in any struggling excitement, or be raised, into the sitting posture whilst under the influence of chloroform, lest cardiac syncope take place. Any tight band around the neck or Avaist should be loosened, the breast had better be exposed, and care should be observed not to subject the thorax or the abdomen especially, to any compression, as the respi- ration becomes principally diaphragmatic. Chloroform may be administered simply on lint or a handkerchief, or by means of an inhaler of some kind. The former mode is in general use, it being equally safe, provided only two precautions be observed; 16 SCIENCE AND PRACTICE OF SURGERY. the chloroform must not be given too suddenly, or the vapour breathed in too concentrated a state or without a free admixture of air. The mode of administration is simply this : a piece of lint or a hand- kerchief folded two or three doubles, and about the size of the hand, is sprinkled with a drachm or two of chloroform; it is then held near the nostrils, but so as to admit a free admixture of air with the first few inhalations; after the lapse of about a minute, a toAvel may be placed over the face of the patient and the hand of the chloroformist to enclose the vapour, still observing to admit the air freely under one corner or one- half of the towel. This is continued, interrupted perhaps by the tem- porary excitement and struggles of the patient, until the arm falls involuntarily and relaxed when raised, and the eyelid ceases to move when the conjunctiva is touched with the finger. During the course of inhalation, the chloroformist should have his other hand on the pulse, carefully feeling its force and frequency, while at the same time he un- ceasingly watches the breathing. If at any moment, earlier or later, during inhalation, the pulse sinks to a feeble, slow beat; or if the breath- ing becomes strongly stertorous; immediately discontinue the administra- tion of chloroform ; and for the relief of the respiration, at once seize the tip of the tongue, with forceps or the fingers, and draw it firmly forwards out of the mouth, until the tendency to obstruction has subsided. The breathing returns with perfect freedom, and the overshadowing lividity of the face disappears. Chloroform can then be cautiously reapplied, if necessary. Inhalers of various kinds have been devised for the purpose of regu- lating the proportion of chloroform and the admixture of air. Snow's inhaler, or Clover's chloroform apparatus, may be employed; and the latter is spoken of very highly by those who have used it, as being most efficient. But simplicity with efficiency is always a great recommenda- tion, and thus the administration of chloroform by means of a piece of lint or a handkerchief can be accomplished at once, when any form of inhaler may not be at hand and would have perhaps to be fetched from a distance of some miles off. Even in Hospitals, inhalers are not commonly employed. In point of safety, the two methods of chloroform-administration are equally available, provided only that a free admixture of air be attended to. I have seen chloroform given in some thousands of cases without an inhaler, during upwards of twenty years, both in Hospital and private practice without a single death, or even an approach to a fatal termination, when the requisite precaution for safety has been observed. Death from Chloroform.—During inhalation, death may occur in three different ways: by asphyxia, by cardiac syncope, or by coma; through failure of the respiration from insufficient aeration, or by laryngeal obstruction; failure of the heart's action; or congestion of the brain. Asphyxia is indicated by the ordinary symptoms : lividity and tur- gescence of the face, violent respiratory efforts, and cessation of the pulse, and of the heart's action. These symptoms may arise simply from deprivation of air resulting in a highly venous state of the blood; but stertorous or snoring breathing is superadded, when the asphyxia arises from laryngeal obstruction. The cause of this obstruction is generally attributed to a " falling back of the tongue," thus mechanically obstruct- ing the entrance of air through the larynx. But Mr. Lister has specially investigated the question, and he finds that the obstruction arises from an INTRODUCTION. 17 approximation of the apices of the arytaenoid cartilages towards, or to, the base of the epiglottis; the stertorous breathing resulting from the vibra- tion of the corresponding portions of mucous membrane, the posterior parts of the arytaeno-epiglottidean folds. Traction of the tongue firmly forwards abolishes the obstruction and stertor, not by any mechanical action on this part of the larynx, for the base of the tongue and hyoid bone remain unmoved in position. It would appear that such traction operates by reflex action through the medium of the nervous system, but whether by inducing or relaxing muscular contraction in the larynx, is uncertain. Cardiac Syncope always occurs suddenly. The patient, after a few inspirations, suddenly becomes pale and faint, the pulse beating almost imperceptibly for a few moments, and then ceasing, although the respira- tion may continue; death taking place by paralysis of the heart. This organ may itself be healthy, but more frequently it will be found to have undergone fatty degeneration. Coma presents the same appearances as asphyxia, but without failure of the heart's action. The face becomes livid, the breathing ster- torous, and the body convulsed; the heart continuing to beat up to the last, as death results from congestion of the brain. This mode of death occurs mostly in epileptics, and in persons affected with uraemic blood- poisoning from old-standing renal disease. These three modes of death are referable generally to the incautious administration of chloroform; whether as regards an excess of chloroform in proportion to the admixture of air, or the prolonged inhalation of this anaesthetic agent. Persistent Sickness is another occasional cause of death; but it occurs after the administration of chloroform, and seems to be a consequence of some idiosyncrasy of the individual. I have only known one case, death having occurred from the exhaustion of continued sickness for four days after amputation of the thigh for encephaloid cancer of the knee-joint, in the person of an otherwise apparently healthy young woman. In another case, after excision of the knee for scrofulous disease, in the person of a young woman, sickness set in and continued for a week; but it was subdued by the hypodermic injection of morphia, while life was sustained by nutritive enemata. Treatment of an Over-dose of Chloroform.—The indication to be ful- filled will vary according as the symptoms, or apparent mode of death, arise from asphyxia, or from cardiac syncope; the object being to re- establish the respiration, or to stimulate and restore the heart's action and the circulation. But in either case, the following directions should be carried out immediately, and in combination:— The administration of chloroform must at once be discontinued. Firm traction of the tongue must be immediately had recourse to, this being effected by seizing the tip of the tongue with fingers or forceps and drawing it well forward out of the mouth. Air must be allowed to circulate freely around the patient, by opening the nearest window and the withdrawal of bystanders. The chest exposed and free of constriction, should be whipped or flagellated Avith a wet towel in order to stimulate reflex respiratory action. This failing, artificial respiration should be resorted to; the best mode being compression Avith the hands just beloAv the sternum, by a sort of c 18 SCIENCE AND PRACTICE OF SURGERY. sharp concussive jerk, folloAved by relaxation for expansion of the thorax, while the tongue is still drawn out of the mouth. Electricity may be employed as the last resource, by applying one pole of a galvanic battery over the spinous processes of the upper cervical vertebrae and the other to the precordial region, so as to stimulate the respiratory and cardiac ganglia. Friction of the extremities, and bottles or cans of hot water to the feet, may also be used, to promote the general circulation. These means of resuscitation should be continued perseveringly while any sign of vitality remains, for it has happened that a patient apparently irrecoverably dead has thus at length been restored to life. Bichloride of Methylene and Chloral are anaesthetic agents which have recently been added to those already noticed—nitrous oxide gas, sulphuric ether, and chloroform. For this addition we are indebted to the experi- mental researches of Dr. B. W. Richardson. Bichloride of Methylene has, Dr. Richardson states, been admi- nistered at present (Oct. 1869) to between six and seven thousand persons with only one fatal termination. It occurred in a patient of Mr. Canton's, on whom he was about reluctantly to operate at Charing- Cross Hospital, for advanced malignant disease of the upper jaw. The patient, a man thirty-nine years of age, was previously exhausted, bodily and mentally, by great suffering of three months' duration, the apparent date of the disease; one nostril was closed by the tumour, thus obstruct- ing respiration, and the patient was subjected to the influence of the bichloride in a sitting posture. One drachm and a half, in separate quantities, had been administered, when the man's head fell back, the pulse became feeble, and then ceased. There was no accompanying stertor nor lividity of countenance. The horizontal position, artificial respiration, and galvanism, failed to restore life. Chloral is, by some observers, said to possess powerful anaesthetic properties; others deny that it is an hypnotic or anaesthetic, but regard it as a powerful excitant. Local Anaesthesia.—The application of cold to a part of the body, in order to reduce the temperature of that part to a frost-bitten condition, is a mode of anaesthesia which may be advantageously employed in certain surgical operations. It is eligible in all superficial and limited operations, in regard both to their extent and the time requisite for their performance. Such are, the avulsion of a toe-nail, puncturing abscesses, slitting up fistulas, and the excision of small tumours. Freezing of the part operated on may be effected either by the application of a frigorific mixture, as introduced by Dr. J. Arnott, or by the ether-spray, devised by Dr. B. W. Richardson. The frigorific mixture of pounded ice and salt is easily made, and answers admirably. This mixture is put into a muslin bag, and applied to the part, being raised in a minute or two to see Avhether the desired effect has taken place. The skin almost immediately loses its colour and becomes white, a change the more observable when previously reddened by inflammation; but this blanching of the skin is no sign of freezing having occurred; soon, however, a dead white, opaque spot appears, quickly spreading over the cutaneous surface, and then the part is frozen and anaesthesia produced. The integument cuts hard, like parchment, and the blood is singularly florid. Reaction speedily sets in, and the part recovers itself. No constitutional disturbance accompanies, or ensues IXTRODUCTION. 19 from, this freezing of a part of the body. I have seen or known only one case of any unfavourable consequence. The patient, a healthy, florid young woman, had sat and seen me remove one of her great toe-nails, looking at the operation with perfect indifference; but when reaction took place, she suddenly fainted, and again and again, until the syncope was alarming. The Ether-spray is another means of freezing a part and inducing local anaesthesia; but in this method it is effected by evaporation of ether thrown upon the surface in the form of a fine spray from a little apparatus contrived by Dr. Richardson for the purpose. It offers a more ready method for the convenience of surgical practice, as it may always be kept at hand; whereas ice cannot always be obtained. Unfortunately, so far as my experience has gone, the apparatus, simple in itself, usually seems to be out of working order Avhen wanted. Dangers attending, or consequent on, Surgical Operation.—The perils pertaining to operation are principally as follows :—(1) Haemorrhage, primary and secondary; (2) Shock; (3) Tetanus; (4) Inflammation; (5) Gangrene; (6) Erysipelas; (7) Pyaemia. Of these different contin- gencies, some are coincident with, others consequent on, the operation. They will all be fully considered in various chapters of this work. Dressing of the Wound, and Constitutional After-treatment.— The dressing of a wound made by surgical operation is the same as that of any incised wound; and the dressings will vary with the supervention of inflammation, and its consequences—Suppuration, Gangrene, and Ulcera- tion. The Constitutional After-treatment must have reference to the various states of the system in the contingencies already alluded to; and to those resulting from inflammation—namely, Inflammatory Fever, Hectic, and Gangrenous-typhoid febrile disturbance. All these states also are considered in their appropriate chapters. Results of Operation.—The object or purpose of any Surgical pro- cedure should be viewed with regard both to its temporary and its per- manent results. An operation may be successful from the one point of view, but not from the other. The unsuccessful results of any Surgical procedure may, perhaps, be reduced to three general heads:—(1) A return of the original condition for which the operation was performed; (2) the substitution of some new condition, not better, or worse, than the first; (3) the inducement of disease in some distant part of the body. Of the two first modes of unsuccessful results, such instances may be cited, as, after amputation of a limb, the return of gangrene in the stump; after excision of a joint, the substitution of a useless limb. The third mode of unsuccessful result is illustrated, after ligature of an artery for aneurism, by the development of aneurism in another part; or after the excision of cancer-growth, the development of internal cancer. C2 PART I. GENERAL PATHOLOGY AND SURGERY. DISEASES OF NUTRITION. CHAPTER I. inflammation. Inflammation may be defined to be a modification of Nutrition; consisting, essentially, in an increased textural productiveness and destruction of texture, and acceleration, therefore, of the nutritive process; resulting in an accumulation of mixed, organized matter,—partly, of products, having an imperfect structural homology or resemblance to healthy conditions of texture or textural elements, and partly, of debris or waste of the textures involved. In connexion with this process of accelerated and imperfect nutrition, the local circulation of blood, and the containing vessels, undergo certain changes; an increased flow or determination of arterial blood to, and in, the capillary vessels, at the seat of inflammation, stagnation and accumulation or congestion of blood in the capillaries of the inflamed part, the veins transmitting the increased current of blood through collateral capillaries — with enlargement of all the vessels concerned, — vascular changes which are accompanied with an effusion or exudation of organizable plasma or liquor sanguinis. The condition of the local circulation in the capillaries is known as the stasis of the circulation in an inflamed part. This complex process has the most comprehensive significance, both pathological and practical; having relation to all Injuries, Diseases, and Surgical Operations. Hence, a due knowledge of Inflammation and its consequences, is of primary importance in the study of Surgery. The pathology of Inflammation is most appropriately introduced by a brief consideration of the physiology of healthy Nutrition,—in the main- tenance of the structural integrity of the body, and the modifications of this process in growth and development. Nutrition is that process, wherein the blood or its constituents as nutritive material—liquor sanguinis, plasma or blastema, is converted into the various textures and organs of the body; thereby restoring or repairing the loss or waste of their structure, which continually accom- panies the exercise of their respective functions. The changes which the nutritive material undergoes are of two kinds :—chemical, in respect to its composition, plastic or formative, as productive of structure; analogous but opposite changes taking place in.the course of decomposition and destruction of the textures. In any diseased modification of Nutrition, as Inflammation, the process INFLAMMATION. 21 is essentially the same in kind, differing only in degree. Hence, the pro- ducts or structural results, and their appearances in course of destruc- tion, are the same, differing only in character. Parallel, but apparently less definite, modifications of chemical composition, may be inferred. The process of Nutrition may be traced, to some extent, in certain tissues, which, being situated on the surface of the body, are open to observation. Epidermic tissues, namely, scarf-skin Or cuticle, nails and hairs, are thus patent. The cuticle, for example, is a layer of cells over- laying the vascular and sensitive true skin. From the latter, a thin, and nearly transparent, serous fluid perpetually exudes, and in this, as a nutritive plasma or blastema, the cuticular cells are formed. Let a portion of cuticle be removed by a blister or a slight burn; the exposed surface is found to be constantly bathed with this fluid. If lightly sponged dry, the surface immediately perspires, as it were, and moistens again. The cells, first formed in this fluid, are soft and round, as seen under the microscope, in newly-formed cuticle. They are also soluble in acetic acid. They give place to similar cells underneath, and as the first formed pass upwards from the true skin, they become dry, hard, and flattened, and acquire the characters of ordinary scaly epithelium; which eventually disintegrates and desquamates from off the surface of the body. A chemical change also accompanies the maturation and destruction of cuticular cells; in this stage, they are insoluble in acetic acid. This twofold process—formative and destructive—is ever going on ; the cuticle being produced, and reduced more or less perceptibly by the decay, death, and shedding of the cuticular cells; they having previously served their function of protecting the subjacent true skin. Molecular disintegration and death, by the constant exercise of func- tion, may be inferred, if not seen, to be proceeding in all other tissues. But constant waste, thus induced, implies constant repair, and the repa- rative material can only come from the blood. This vital fluid must, therefore, present an appropriate composition for the repair of each com- ponent tissue of the body, and must also be supplied in adequate quantity thereto, as all the tissues are alike undergoing incessant destruction. Assuming this twofold condition of quality and quantity of blood, due to the tissues severally; they, on their part, select and secrete or separate from the blood-vascular system, as the common reservoir, that kind and quantity of plasma which is appropriate for their individual nutritive maintenance. The blood is thus left reduced in quantity, and, moreover, deprived of those constituents which have entered into the formation of the tissues. But, as each tissue draws its own particular nourishment, the residual mass of blood, in circulation, becomes relatively adapted, in quality, for the proper nourishment of other tissues, of dis- similar composition. The tissues, severally, in their functional relation to blood-elaboration, are thus excreting organs. The blood is renewed in quantity, and further maintained in quality, by the co-operation of other functions,—digestion, excretive secretion, and respiration; while its circulation is regulated by the 'agency of the nervous system. Again and again is this fluid, replenished and reno- vated, distributed to every part of the body, each tissue claiming and retaining that quantity of the common pabulum which may be necessary, and selecting those ingredients Avhich enter into its own formation, to repair its Avaste and thus maintain its substance. Growth and Development.—It will be obvious that any increased 22 GENERAL PATHOLOGY AND SURGERY. nutritive demand, beyond that of mere maintenance—as by GroAvth, necessarily implies at least an increased supply of blood to the part undergoing this change, and perhaps also a different quality of blood to meet any such additional requirement. Indeed, ever moving and vibra- tive as are the leaves of an aspen tree even on a breathless summer's day, so likewise oscillatory is the nice adjustment and equilibrium of nutrition. The balance of maintenance could never be continued from hour to hour, scarcely from minute to minute, without a varying capacity in the circu- latory system to satisfy ever-varying demands. This provision would seem to be brought into action by nervous influence. For, not a sensation thrilling, not a thought inspiring, not an emotion agitating ever so gently, but forthwith there is a flush of arterial blood with life-giving energy; manifesting the Avide-spreading agency of the nervous system. In some instances, this rush of blood is visible, as in blushing. By analogy, it is probable that any act of volition in like manner relaxes and enlarges the capillary vessels of the muscle or muscles to Avhich it is directed, through the medium of the nervi-vasorum. The flow of nervous influence, or vis nervosa, which excites contraction of the voluntary muscular fibres, would thus simultaneously relax the involuntary fibres of the smaller vessels. The waste of muscular tissue incurred by each slight momentary move- ment, and, therefore, more so by continued exercise, would consequently be repaired by an adequate flow of blood. Proportionate also to the act of volition as is the exercise and accompanying waste, so also may be the enlargement of the nutrient vessels, and consequent flow, or supply, of blood. Determination of blood it might then be called. But, this influence of the nervous system by volition is a physiological probability only, not a fact, as yet actually demonstrated. Development contrasts with growth, in representing the quality, as well as quantity, of structure produced. But the two are concurrent and co-equal manifestations of the formative power, in healthy Nutrition. It would appear that emotional influence is not limited to apportioning the supply of blood, and thence the quantity of growth or the size attained by a part subject to such influence; the quality or kind of growth produced, is also, in a measure, regulated thereby. For example, a fatty tumour was removed by Mr. Lawrence, several years ago, from a woman's shoulder ; and when the wound had healed soundly, she imagined the tumour to have been a cancer, and that it would return. By accident, Mr. Paget saw her some months afterwards, and she had a large and firm painful tumour in her breast, which was not removed, for its nature was obscure and her general health unfavourable. Some months subsequently, having become Mr. Paget's patient at the Finsbury Dispensary, her health had much improved, but the hard lump in her breast still remained, as large as an egg, and just like a portion of indurated mammary'gland. She Avas assured by Mr. Paget that her supposed cancer Avould disappear; and it did become very much smaller, Avithout any help from medicine. As this tumour had arisen under the influence of fear, so it very nearly subsided under that of confidence. The patient was lost sight of before the tumour had been completely absorbed. In this summary of the process of Nutrition, we observe a co-operative relation subsisting betAveen its essential conditions :—textural changes; and the blood, in quality and quantity, as representing the nutritive material; accessory to which are the blood-vessels Avhich convey the blood to the part nourished; and the nerves in connexion therewith, INFLAMMATION. 23 which further regulate the supply. The accessory character of the two latter conditions is also evinced by the fact of Nutrition taking place in comparatively avascular textures, and those which are destitute of nerves; as cartilage. Thus then is Nutrition maintained; and we also observe in these conditions adequate provision for the extra demands of Growth and Development, whereby blood is duly determined to textures or parts undergoing this tAvofold physiological change. Reparation of texture, after destruction by injury or disease, is subject to the same conditions. The processes of primary adhesion, immediate union, suppurative granulation,—with perhaps secondary adhesion, and scabbing, as described in subsequent chapters, may therefore be properly associated with this general consideration of the physiology of Nutrition. Inflammation is another modification of Nutrition, the same elements co-operating. This process can be observed when it takes place in tex- tures on the surface of the body, as the skin; and it is best illustrated when occasioned simply by a burn or other injury, rather than when induced by the operation of a blood-poison, as in erysipelas, boil, or carbuncle ; which are specific and complicated illustrations of inflam- mation. (1) Textural Changes.—The twofold nature of the textural changes in Inflammation, is the same as in healthy Nutrition ; but the textural pro- ductiveness and the destruction of texture, are both increased, and the process proceeds more rapidly. Hence, the products are not only increased in quantity, they are also imperfect structural conditions of textural elements, by various degrees of arrest of their development; such as exudation and pus-corpuscles, coagulated fibrin with plastic corpuscles, granular matter, and serum; while the debris or waste matter of the tex- jture is apt to accumulate. In virtue of its increased productiveness, inflammation differs from ' nutritive-maintenance, and is allied to growth; but in virtue of its rapidity, the process is so hurried on, that more is accomplished in a given time, and consequently the products are imperfectly developed. Accelerated Nutrition would therefore seem to be an appropriate name for Inflammation, as at once expressing its nature and distinctive character. (2) State of the circulation of blood, and of the blood-vessels, in rela- tion to, and in, the part inflamed.—This element of inflammation neces- sarily pertains to vascular textures; nevertheless, comparatively avascular textures, such as cartilage, which are nourished by imbibition, are affected by the circulation of blood in the adjoining texture, whence they derive their nutritive material as the source of supply. The blood current to, and from, an inflamed part, through the arteries and veins respectively, is increased in quantity, force, and rapidity; so also it would appear to be primarily increased in the capillaries of the part, but secondarily it becomes stagnant, a condition known as the stasis of the circulation in those vessels. The arteries, veins, and capillaries all apparently become enlarged. Enlargement of the arteries, with increased flow of arterial blood through them, constitutes determination of blood; enlargement of the capillaries, with stagnation or accumulation of blood in them, constitutes congestion of blood ; the enlarged veins transmitting the increased current of blood, through collateral capillaries. In inflammation, the presence of determination of blood, subsequently of congestion, and possibly the co-existence of both these vascular con- 21 GENERAL PATHOLOGY AND SURGERY. ditions, are facts, which have been more or less established by the follow- ing experimental observations. (a) Arterial and Venous Circulation.—The arteries towards an in- flamed part throb Avith increased pulsation, while the veins therefrom are turgid. It might appear that the former are beating with blood apparently rebounding from some obstruction in advance, and that the latter become turgid with stagnant blood. But experimental observa- tions demonstrate the accelerated rapidity and force of the blood's motion to, and from, an inflamed part. Let an artery toward a part inflamed be divided, and the blood is seen to be ejected to a much greater distance than that from an artery of the same size and distance from the heart, but not contiguous to an inflamed part. This increased propulsion was noticed by Dr. John Thomson,* when the arteries of a finger were divided in whitloe, and when those of the prepuce, much inflamed, were cut in the operation for phymosis. More exact, because comparative and otherwise complete, was the observation of Mr. Lawrence.f One hand of a patient being inflamed, venesection was performed, at the same time, and in a similar manner, in both arms: the vein from the inflamed hand yielded about three times more blood in a given time than the vein from the uninflamed hand. The blood's motion from the part was increased. Enlargement of the arteries leading to an inflamed part, in the human subject, is rendered probable by Hunter's well-known experiment on a rabbit. Hunter froze the ear of a rabbit, and thawed it again ; acute in- flammation began, with increased heat, and considerable thickening of the part. The rabbit was killed when its ear was at the height of inflam- mation. The head was then injected, and the two ears were removed and dried. The uninflamed ear dried clear and transparent; its vessels were distinctly seen ramifying through its substance ; but the inflamed ear dried thicker and more opaque, and its arteries were considerably larger. (b) Capillary Circulation.—The state of the capillary circulation in in- flammation, and the condition of stagnation or stasis, has been observed in the transparent parts of certain animals, chiefly in the web of the frog's foot, and in the bat's wing. Conclusions drawn from such data relative to the human organism, are inferential only, the physiological and structural conditions being dissimilar. Yet these inferential conclusions represent the remainder of what is known respecting the nature of inflammation, in the human subject. Determination and congestion of blood, are, according to some observers, said to co-exist at the seat of inflammation. Dr. C. J. B. Williams main- tains this view ; and also that the resulting compound state-inflammation may originate either in determination or in congestion, or in the concur- rence of both simultaneously. To illustrate the origin of inflammation by the concurrence of deter- mination of blood and congestion, Dr. Williams adduces observations made on the web of the frog's foot. " If," says he, " a strong irritant, as a grain of capsicum, or a minute globule of essential oil, be applied to the web, all its blood-vessels speedily become enlarged; those most irritated * Lectures on Inflammation, 1813, p. 67. t Lond. Med. Gaz., vol. v., 1829. INFLAMMATION. 25 are very large and red, and the blood in them is stagnant and coagulated, contiguous vessels are also very large, but less red, and the motion of the blood in them is slow, and often in pulses or oscillations; whilst in vessels beyond, the enlargement of the capillaries is less considerable, but that of the arteries is obvious, and the current of blood is very rapid."* This state of co-existing congestion and determination of blood, as resulting from over-irritation of the web of a frog's foot, may be inferred to occur also in the human subject. But in other animals than the frog, congestion occasioned by venous obstruction, produced artifi- cially, actually averts determination of blood : therefore, experimental observation equally justifies the inference, that diminished motion of blood cannot be, in the human subject, an essential part of inflammation— a process which certainly implies determination. Thus, the experiments of Macartney appear to me conclusive evidence that determination of blood is prevented in rabbits by congestion arising from venous obstruction. The most remarkable circumstance, observes this authority, with respect to congestion, and the one which has not hitherto been described, is that arteries found in a congested part are smaller than their natural size. Both the jugular veins of a rabbit were ligatured ; the animal died apoplectic, and upon examining the vessels of the ears, the veins which lie towards their outer edge were found greatly enlarged and gorged with dark blood ;*but the artery which runs in the centre of the ear was reduced very much below its natural size, so that it appeared as a mere line. Another experiment showed the instantaneous effect of arresting the venous circulation. The mesentery of a young rabbit was exposed, and the trunks of several mesenteric veins having been tied, their correspond- ing arteries contracted immediately in the most palpable manner and to a very small size, as if, significantly adds Macartney, taught by their organic instinct that blood should not be permitted to go where it must immedi- ately return.* The causes of congestion of the capillaries in inflammation, are said to consist in the state of these vessels, and of their contained blood; the former becoming dilated, lengthened, and tortuous, as the result of their weakness and inelasticity from over-irritation; the latter being an im- pacted state of the red-corpuscles, and increased production of the pale- corpuscles, which are also more adhesive than in health, and cling to the sides of the vessels. But, equally untrustAvorthy as are experiments on the frog's foot, the bat's wing, and other transparent parts of animals, to determine whether congestion be an element of inflammation in the human subject, are similar observations to ascertain the condition of the capillary vessels and of their contents in the state of inflammation. Assuming the experimental observations of Dr. Williams on the web of the frog's foot to be accurate, the dilatation, lengthening, and tortuosity which he describes in respect of these vessels, are at the best but data for conclusions, indirectly—grounds of probability only—as to the condition of the capillaries during inflammation in any part of the human body. No one has ever seen the appearances of the capillaries in the human sub- * On Inflammation, 1838, p. 141. 26 GENERAL PATHOLOGY AND SURGERY. ject, either during inflammation or in the healthy living condition ; nor can we follow with faith in the assumption that because red blood-discs become impacted, and white blood-corpuscles are apparently more abundantly developed and more adhesive than usual, clinging and lingering round and round on the walls of capillary vessels in the web of the frog's foot; therefore there is a similar blockade of these discs and Avaltzing of these corpuscles in the capillaries—say of the conjunctiva of the human eye when inflamed. In point of fact, the capillary circulation of a warm-blooded animal under the same circumstances does not present these appearances. Paget and Wharton Jones both watched and failed to discover any undue display of white corpuscles in the bat's wing, and the former authority attributes the large proportion of these corpuscles noticed in the frog to an unhealthy condition of this animal. According to Professor Lister's experiments, inflammation consists apparently of a series of changes, in order as follows:—(1) A suspension of the concurrent exercise of function among the minute elements of the tissue. (2) Derangement of the blood, which, in the vicinity of the im- paired tissue elements tends to assume the same character as blood ahvays acquires when in contact with ordinary solid matter, and which renders it unfit for transmission through the blood-vessels. A return of the tissue elements to their usually active state will be associated with a restora- tion of the blood to a condition fitted for circulation. (3) The arteries are narrowed, and the blood flows through them with greater rapidity. (4) The same vessels subsequently become enlarged, and the current of blood is slower, although uniform. (5) The flow of blood becomes irregular. (6) All motion of the blood ceases, and complete stagnation ensues. (7) The liquor sanguinis may be exuded through the walls of the blood-vessels, sometimes accompanied by the extravasation of blood- corpuscles, owing to rupture of the capillaries. In tracing the process of Inflammation, it is difficult to determine the order of succession in the changes which essentially constitute this pro- cess. The question of priority, therefore, on the part of the textures or the blood, is doubtful. Whether an increased textural productiveness and consequent demand for nutritive material, induces an extra flow of arterial blood towards this focus of accelerated nutrition; or whether a determination of blood solicits the formative power of the textures to more active, albeit abortive operation ? The latter vieAv, originally advocated by John Hunter, long held un- disputed acknowledgment in the schools and in medical literature; before the textures were discovered, so to speak, by Bichat, and before the grand and fertile theory of cell-development introduced by Schwann and Schleiden. But the independent vitality of the textures in relation to the blood, a physiological doctrine probably entertained by Haller, was subsequently extended to pathology by Hebrenstreit, Burdach, Alison, and others; while, in respect to Inflammation especially, this doctrine is strenuously advocated with great originality of argument by Virchow,* and exclusively adopted by Mr. Simon,"j" and other pathologists in re- cent works. For the discussion of any other doubtful points respecting the intimate nature of Inflammation, and more particularly as investigated in animals, * Cellular Pathology. Trans, by F. Chance, 1860. t System of Surgery. Ed. by T. Holmes, 1860, vol. i. p. 6. INFLAMMATION. 27 the reader is referred to abundant sources of interesting information in the writings of Wilson Philips, Kaltenbrunner, Gerber, Gendrin, Miiller, Lebert, Alison, Henle, Addison, Gulliver, Wharton Jones, C. J. B. Williams, Bennett, Paget, and Joseph Lister. Signs.—The local signs of inflammation are redness, heat, SAvelling, and pain; the first three being objective phenomena, pain, a subjective symptom, and there is also some functional disturbance or loss of func- tional power in the part affected. (1) Redness is a sign of inflammation, owing to the determination of arte- rial blood; but the development of this sign will be proportionate to the number of capillary vessels pervading the part, and the extra flow of blood through them. The colour, a florid hue, varies according to the arterial or venous character of the blood, and as shaded by any inter- vening texture; or it may be entirely unseen through the depth of integu- ment concealing the engorged vessels. Their engorgement, or hyperaemia, presents different shapes, according to the peculiar anatomical arrange- ments of the capillaries in the texture or part. Hence punctiform, stellate, arborescent, maculiform, or spotted, and uniform blush-redness, are frequently recognised, as in the skin and mucous membranes which are open to inspection. Redness, such as I have described, is the earliest announcement of inflammation, and also its most exact indication, being invariably present, even Avhen unseen, a sign of no other kind of hyperaemia, and the measure of its own. The exceptional case of a growing part—e.g., the gravid uterus, having similar redness, scarcely invalidates the general fact that this sign is, otherwise, peculiar to inflammation. Nor does its excep- tional absence in extra-vascular tissues—e.g., cartilage and the cornea, affect the otherwise general constancy of this concomitant hyperaemia. Even in such cases the adjoining textures exhibit its characteristic appearance, as by a zone of redness around the cornea, in corneitis, and increased vascularity of the adjoining bone, in inflammation of cartilage. In either case, the seat of hyperaemia coincides with the capillary plexus which is subservient to the healthy nutrition of the part inflamed. Redness from the development of new vessels in an inflamed part is not an early occurrence, but a consequence of the process of inflammation. (2) Heat is another local sign, partly due to the determination of blood; as such it is proportionate thereto, and to the number of vessels through which the extra supply of arterial blood is passing. But the increase of temperature will be perceptible only according to the superficial situation of the inflamed part, and the facility with which heat is transmitted through any intervening textures. Is heat generated by inflammation ? The flow of arterial blood, and therefore of red blood-corpuscles charged with oxygen, may possibly gene- rate heat. Yet the experiments of John Hunter shoAV that the tempera- ture of an inflamed part never rises more than two or three degrees, and scarcely, if ever, above the average heat of arterial blood—say, from ninety-eight to one hundred degrees Fah. On the other hand, the more recent " thermo-electric " observations of Mr. Simon* and Dr. E. Mont- gomery are apparently conclusive on this point—that an inflamed part is * System of Surgery, edited by T. Holmes, 1860. Vol. i., Inflammation, by J. Simon, p. 42. 28 GENERAL PATHOLOGY AND SURGERY. no mere passive recipient of heat, but is itself actively calorific. For among the observed results are these:— " That the arterial blood supplied to an inflamed limb is found less warm than the focus of inflammation itself. " That the venous blood returning from an inflamed limb, though found less warm than the focus of inflammation, is found warmer than the arterial blood supplied to the limb ; and " That the venous blood returning from an inflamed limb is found warmer than the corresponding current on the opposite side of the body." Granting, then, that the inflammatory process unquestionably involves a local production of heat, "to interpret this fact," adds Mr. Simon, " is perhaps, in the present state of physics, not possible." Whatever be the source of increased heat, it continues with the in- flammation, unlike the transient warmth of blushing, or other non-inflam- matory determination of blood. Respecting its diagnostic value, the increased heat arises at the same time as the redness; it is an equally early, if not an equally exact sign of inflammation. (3) Swelling.—The persistence of inflammatory determination of blood is accompanied with the appearance of lymph and serum, and con- sequent swelling in a greater or less degree; unlike the issue of that temporary distension of the vessels, which ordinary determination of blood denotes. By this persistent increased flow of blood, the surcharged vessels would appear to be gradually relieved by effusion of the liquor sanguinis. Virchow* ventures to advance the hypothesis, " somewhat bold per- haps, though perfectly able to sustain discussion: that, fibrin generally, wherever it occurs in the body external to the blood, is not to be regarded as an excretion from the blood, but as a local production. Nobody," he alleges, " has ever been able by the production of a mere change in the force of the current of the blood to induce the fibrin to transude directly, as it is wont to do in certain inflammatory processes; for this some irritation is always required." Accordingly, in respect of inflam- mation, Virchow regards fibrin, not as an exudation or effusion from the vessels by persistent (inflammatory) determination of blood, but as " an educt from the vessels, in consequence of the activity of the histological elements themselves."j- Professor Bennetti. suggests that the tissues attract the fibrin, which, however, pre-exists in the blood. The engorged vessels themselves occasion some degree of swelling of the part; an increase proportionate to the vascularity of the part, and to the degree of turgescence of its vessels. Full-blooded internal organs become most swollen in this way, such are the lungs, liver, spleen, and kidneys when inflamed. But with persistent engorgement further enlargement ensues by effusion, and the situation, size, shape, and physical characters generally of this swelling, will, for the most part, depend on the kind of structure in which it takes place. Liquor sanguinis is readily effused into the constituent cellular texture of the organ, or part inflamed, and therefore most readily into the sub- stance of loosely parenchymatous organs; frequently, moreover, the most vascular, such as those just enumerated. Lymph and serum overflow into * Cellular Pathology. Trans, for Syd. Soc. by F. Chance, 1860, p. 162. t Ibid., p. 366. + Clin. Lectures on Medicine, 1858, p. 133. INFLAMMATION. 29 cavities—e.g., into serous membranes and synovial sacs. These and similar structures solicit the overloaded vessels to relieve themselves, and their size becomes enlarged, in a corresponding measure, by inflammation. Witness hepatized lungs from pneumonia in its second stage—immense enlarge- ment of the liver from chronic inflammation; enormous increase of the spleen, forming the ague-cake by an analogous process; and the immense size to which the kidneys attain by chronic nephritis and Bright's disease. Phlegmonous erysipelas—engaging, as it .does, the subcutaneous cellular tissue deeper and deeper—is characterized by considerable swelling. Witness the opposite results in tight unyielding textures—such as effusion beneath fasciae and in fibrous textures generally, and an abscess formed in the substance of bone, but unattended with any perceptible swelling, and suspected only by the intense and unremitting pain it occasions. Certain textures allow of an intermediate amount of swelling between the extremes presented by cellular and fibrous tissues. Such are the degrees peculiar to the skin and mucous membranes. Of the latter I may mention pulpy thickening of the large intestine in cases of chronic dysentery, while swell- ing in some measure of the skin is one feature of most of its eruptions, however otherwise diversified their appearance may be—as rashes, scales, papules (pimples), vesicles, pustules ; and most conspicuously this is the character of solid tubercular swellings, such as occur in secondary syphilis. The shape of inflammatory swelling is also a mixed result, principally due to the kind of structure into Avhich effusion takes place ; partly, how- ever, to the kind of matter effused. If thin serum, the SAvelling will be fluid, fluctuating, and diffused; if coagulating lymph be poured out, it will be more solid and circumscribed. I shall not attempt to describe the various degrees of density or consistence which inflammatory swelling presents, as resulting from the combined influence of the kind of matter effused, and that of the receiving structure. These alterations may be of two kinds : softening, chiefly in connexion with acute inflammation, and indurati on, chiefly in consequence of chronic inflammation. The diagnostic value of inflammatory swelling is not equal to that of redness. It is necessarily a later sign than redness, which always precedes effusion by an important and often appreciable period of time. Iritis is announced by injection of the ciliary arteries and a zone of redness around the iris, before the perilous effusion of lymph. Erysipelas spreads with a red blush before the disorganizing engorgement of the subcutaneous cellular tissue. Regarded as an exact sign, although some degree of swelling invariably follows inflammatory determination of blood, and although the nature of an obscure swelling is assured, if not by its physical properties, at least, by puncture, and if necessary by further examination with the microscope of the material of the swelling; yet these guarantees of identity are the only unequivocal advantages of this sign. Unlike redness, it is no measure of the degree of inflammation. The most intense may produce a trivial swelling in an unyielding texture, and a trivial degree of inflammation Avill soon exhibit considerable swell- ing in a loose tissue. Subject to these disqualifications, swelling is the more valuable sign, practically speaking, of inflammation. It can be discovered when the redness cannot be seen. In all superficial textures and parts, swelling can be readily detected. The skin, cellular texture, muscles, periosteum, bone, blood-vessels, and lymphatics, and the component tissues of the 80 GENERAL PATHOLOGY AND SURGERY. joints severally present each a characteristic SAvelling when inflamed. Certain internal organs are also open to examination—e.g., the pelvic viscera, excepting the bladder. Thus, inflammatory enlargement of the prostate, or the uterus, and thickening of the rectum, can be felt, and possibly seen. Certain other organs are indeed beyond the reach of vision and the direct application of the hand, yet the ear can then detect effusion and swelling by means of percussion, as of the liver, gastro- intestinal canal, and spleen; and this may be aided by auscultation, as of the heart and lungs. (4) Pain.—Observe, the influence of swelling. No sooner has the first contribution toward swelling been made by persisting distension of the vessels of the inflamed part, than pain, or at least exalted sensibility, is induced by the blood's influence on the nerves of that part. The degree of pain from this cause will be regulated by both the elements which determine the amount of hyperaemia, that is to say will be propor- tionate to the determination of blood, and the number of vessels in the part; but the number of sensory nerves affected will further apportion the degree of pain. As swelling ensues from effusion, the same conditions which represent the degree of tension, will also measure the intensity of the pain. Thus a more solid, and therefore circumscribed effusion of coagulating lymph, underneath an unyielding texture, such as a fibrous membrane—e.g., the fascia-lata, or a fluid similarly circumstanced, as an abscess in the substance of bone, are aggravating conditions inducing the most severe and unremitting pain; while a more fluid serous effusion into a loose texture such as the cellular tissue, say of the arm-pit, allows of a more considerable accumulation without much pain, and will then be more tolerable. Pain is also attributed to structural change in the nerve- fibrils of the inflamed part. (Simon). The character as well as the degree of pain accompanying inflamma- tion, is equally diversified. A burning pain in erysipelas, Avhence the popular name of this disease—St. Anthony's-fire. A scalding pain in inflammation of the rectum, during evacuation of the faeces. Chronic rheumatism and lumbago are attended with the dull aching pain of inflamed fibrous and muscular tissues; gout, with a wrenching pain; abscess in bone, with an unremitting burrowing pain; inflammation of the dental periosteum-periodontitis, with a throbbing pain. In other parts this character of pain is the known forerunner of suppura- tion. Parts endowed with but little sensibility in health, generally become acutely sensible when inflamed; as fibrous textures and bone, including the teeth; the intestinal canal in enteritis, the pleura and peritoneum respectively, when inflamed. Parenchymatous organs like- wise acquire exalted sensibility, as manifested by the heavy, oppressive pain of pneumonia. Organs of special sense are for a time quickened by inflammation, and convey their own sensations but too keenly. The ear becomes too susceptible of sound, and iritis begets intolerance of light. Reflected pains in distant parts are not uncommon symptoms of in- flammation. Pain in the inner side of the knee may emanate from inflammation of the hip-joint; in the glans penis, from cystitis; in the testicle, from nephritis; under the right shoulder-blade, from hepatitis; and under the left scapula from gastritis. Reflex motions may be excited in like manner : Sneezing, by catarrh; coughing, by bronchitis and pneumonia; vomiting, by gastritis: and (reflex ?) micturition, by cystitis. INFLAMMATION. 31 The diagnostic value of pain is comparatively little. The pain of in- flammation being chiefly due to swelling, is scarcely an earlier sign. It is also the most inexact sign; pain may be absent in true inflammation, and present without; and is rather a measure of the kind of swelling than of the degree of inflammation. By itself, therefore, pain has little diagnostic importance. (5) The function of the organ or texture affected, undergoes certain changes, which constitute additional local symptoms of inflammation. They may be described in general terms, as exaltation of function, followed by its depression, and various perversions of function having an intermediate character. Thus, with inflammation of the brain ; delirium, increased sensibility and convulsions, are succeeded by stupor and para- lysis. Inflammation of the spinal cord presents similar symptoms; ex- cepting of course any modifications of purely cerebral functions. With nephritis, the secretion of urine is first increased, then diminished; and so with regard to other secreting organs. In pneumonia, dyspnoea repre- sents increased respiratory effort, but this is attended with imperfect aeration of the blood and the retention of hydro-carbonaceous matter. Accumulation of excrementitious matters in the blood is the most serious consequence of inflammation affecting any specially excreting organ; as the kidneys or skin. By itself, pain has, we have seen, but little diagnostic importance; yet from this point we can trace the origin of inflammatory fever. Constitutional Symptoms—Inflammatory Fever.—The phenomena of this fever are briefly these:—the heart's action is excited, the pulse becoming more forcible and frequent than usual, and in some cases, less compressible; the skin is dry and hot, the urine scanty and high-coloured, the tongue furred, the bowels probably constipated, and the faeces dry and hard; thirst and inappetency, Aveakness with general nervous excitement, —restlessness, sleeplessness, and hurried respiration, are also primary phenomena. Hence, the vascular, secretory, and nervous systems, are together engaged in a constitutional disorder—symptomatic of the local inflammation. Febrile urine exhibits physical characters and chemical peculiarities of peculiar importance. At first, it has a deep red colour, strong urinous odour, super-acid reaction, high specific gravity; and the quantity secreted in a given time is diminished. These alterations are chiefly owing to a reduced proportion of water, rather than of solid constituents in the urine, which has thus become concentrated. But the inorganic salts, especially the chloride of sodium, are diminished, both absolutely and relatively; while, uric acid and the urates are increased. Even when urates are not deposited, there is always an excess of uric acid. Urea is increased in some cases, and probably diminished in others. The greatest quantity present would appear to be in meningitis, and an excess is found during exudation; but urea is diminished during resorption, in pneumonia, pleurisy, and in acute rheumatism, especially if accompanied with endocarditis. Extractive matter is generally increased, and lactic acid is often present. Occasionally, a small quantity of albumen is found, but only for a short time. As inflammatory fever declines, the urine deposits a lateritious or brick-dust coloured sediment, more or less abun- dant, consisting of urate of ammonia. The quantity of sweat is much diminished during inflammatory fever, but its chemical composition at that time is not well understood. Ulcers, 32 GENERAL PATHOLOGY AND SURGERY. also, which have been discharging freely become dry. The flow of saliva is less free, and the tongue furred. This appearance arises from a material of whitish yellow or brown colour and firm consistence, overlaying the posterior and middle portion of the tongue on its upper aspect, and adhering closely. It cannot be removed altogether by scraping, but as the fever declines it is shed spontaneously. If, says Dr. Thomson, this furr arose from the nature of the saliva secreted, then, instead of being found only on the upper, middle, and posterior parts of the tongue, Ave should find it incrusting the whole internal surface of the mouth. It is probably secreted from the papillae to which it adheres. A similar appearance arises from irritation of the stomach, Avithout any fever at all. Dis- crimination, therefore, is necessary, by considering whether other symptoms concur. Blood.—The Blood undergoes certain very important alterations in inflammation, and which are of two kinds ; namely, in respect to its vital properties, and therefore as affecting its coagulability and coagulation; and in respect to its chemical composition. The altered vital properties of the blood comprise: an increased tendency to coagulation, and to the separation and contraction of the fibrin in a free state. The phenomena known as the buffy coat and sizy blood are thus produced. These appearances can be understood by comparing the changes which take place, as observed in the coagulation of healthy blood. Let a pint of fresh-drawn blood be exposed in a shallow basin ; im- mediately a vapour, having a faint odour, arises, which {halitus) was first noticed by Haller. In about four minutes a pellicle appears at the edge of the vessel, soon extending over the surface of the blood and down the sides of the vessel. It pervades the whole in about eight or nine minutes. The fluid blood is thus converted into a jelly. But in a variable period, from seventeen to twenty minutes, or much later, this jelly begins to shrink away from the sides of the basin, and the colourless, transparent serum exudes—a process which, continuing for several hours, or even days, at length leaves a blood-red clot, floating about in limpid serum. And what is this clot ? The fibrin of the liquor sanguinis, which has spontaneously solidified into fine homogeneous filaments, interwoven like felt, and which has caught and involved the red corpuscles. They also have spontaneously aggregated, their disc-shaped surfaces cohering side by side, and forming rouleaux, like piles of money, Avhich then con- nected themselves into an irregular network ; the shrinking of this fabric, intertwined with that of the fibrin, expressed the serum, and thus aided the solidification of the clot. Two constituents, therefore,—the fibrin and red discs,—together spontaneously aggregate to form the clot, which consists of woven filaments, involving the net of red-discs. The expressed serum is structureless. The pale or colourless corpuscles are irregularly distributed throughout the clot and serum. These changes are represented in the following table. „. ., „, , ( Liquor Sanguinis. (Serum. 1 Fluid Blood. < H ° \ Fibrin. ) CM j Coagulated Blood. The experimental observations of Dr. B. W. Richardson* apparently demonstrated that this process of coagulation is essentially associated with * The Cause of the Coagulation of the Blood, 1858. INFLAMMATION. 33 the elimination of ammonia—a most significant fact. More recently however, the observations of Professor Lister* tended to negative this conclusion ; and it is, I believe, regarded as no longer tenable. If the blood, freshly drawn as we have supposed, be inflammatory, its coagulation then presents a clot, the upper portion of which is pure fibrin, of a tawny-yellow colour, and known as the buffy coat. This, therefore, consists of a portion of fibrin, which has coagulated apart from the mesh formed of red discs. And what is the immediate cause of this kind of clot ? Obviously, that the red discs separated and subsided from the liquor sanguinis before the fibrin began to coagulate. Hoav does such isolation arise ? Possibly in either of two ways, or by a concurrence of both. The fibrin may coagulate so slowly as to allow time for the blood-discs to separate and subside. But Dr. Stokes j watched the coagu- lation of inflammatory blood in twenty-seven cases. In fifteen of them the buffy coat formed; in the remaining twelve it did not. In four of these twelve samples of ordinary coagulation, it began only at the end of eight minutes after venesection, and in other three of this series not until after twenty to forty minutes had elapsed—making a range between the two extremes of from eight to forty minutes. This delay of coagulation gave ample opportunity for the red discs to escape from the fibrin during its solidification; yet they did not subside, and the usual red clot formed. On the other hand, in twelve of the fifteen samples of buff-forming coagu- lation, the yellow clot of pure fibrin formed in only five minutes, and in the remaining three it Avas delayed only to ten minutes; so that, during this comparatively short period of fi\re or ten minutes, the red particles had separated and settled down, leaving the buff-coloured fibrin free and floating. Slow coagulation, therefore, does not explain the production of the buffy coat. The only other active element in coagulating blood is the mesh-forming1 discs; and how do they behave in freshly-drawn inflammatory blood ? They individually possess undue power of aggregating (H. Nasse), and the net thus-wrought has also undue power of contracting (W. Jones), whereby the serum is more effectually expressed from its meshes. This fabric, therefore—the component particles of which have individually greater specific gravity than the serum—has now even greater weight, bulk for bulk, and being formed earlier than usual, subsides in the serum before the fibrin has fairly solidified, or perhaps before this more essential element of the clot has begun to coagulate. John Hunter seems to have anticipated this view of buffy blood, and Schroeder Van der Kolk, with other ob- servers, have corroborated it. Combining all these observations—formation of the buffy coat seems to imply an increased separation and contraction of fibrin in a free state, rather than its increased power of separation and contraction, and that the blood-discs are the initiative and active element in the process of buff- forming coagulation. Slow coagulation of the fibrin Avill, hoAvever, favour this result, by allowing more time for the gregarious blood-discs to flock together and exercise their function as a contracting mesh. If, therefore, the blood be artificially preserved in a fluid state, by adding serum to above its propor- tion, thereby delaying coagulation; ths red-discs aggregate and subside, and the buffy coat is presented. * Lecture before the Royal Soc. Lond., Lancet, 1863, Vol. ii., Nos. vi. vii. f Brit, and For. Med.-Chir.-Rev. D 34 GENERAL PATHOLOGY AND SURGERY. Probably all the causes I have mentioned concur to produce this result, and that as they prevail more or less during the act of coagulation so is the buffy coat of pure fibrin more or less completely established. The earliest intimation that blood is about to undergo this kind of coagulation, is the appearance of a violet tint, not unlike the bloom of black Hamburg grapes, on the surface of the exposed blood. This appearance was, I conceive, noticed by Hunter, and regarded by him as due to the red particles shining through a thin layer of buff-coloured lymph, just as blood in the veins gives a similar tint when viewed through the skin. The tint will therefore vary as the layer of fibrin becomes thicker. Coagulation proceeding, if the mesh of red particles separate and subside from the fibrin, but yet slowly and incompletely, and if the free fibrin but imperfectly solidifies and contracts, then a loose sizy clot is produced, resembling a solution of isinglass, attached to the sides of the vessel, and scarcely trembling when shaken. If, again, the separation and contraction of pure fibrin be more complete, a flat, yellow buff-coloured cake is pro- duced, swimming in serum ; but the under portion of this clot is red as usual by admixture of the red discs. If, again, the separation and con- traction of fibrin be still more complete, the fully-formed, solid, and buff- coloured clot is presented, withdrawn from the sides of the vessel, and probably concave or cupped on its upper surface: the lower portion of this clot having formed more slowly, has therefore contracted more strongly, and drawn down the central part of its upper aspect. The blood, or rather clot, is buffed and cupped. E\ren in such case the red particles and fibrin do not completely separate. In thirty samples of buffed blood, carefully inspected by Dr. Richardson,* he never failed to find red discs in the lower portion of the clot, and in many instances this red lower portion had the consistence of ordinary coagulum. The diagnostic value of these appearances is not absolute. Invariably present with inflammation, they are also present in other conditions affect- ing the blood. Coagulation exhibits the buffy-coat notably in pregnancy, and other conditions attended with an excess of fibrin in the blood ; and both the buffed and cupped appearance may proceed from slow coagulation, without any change in the constitution of the blood itself, as when this fluid is drawn quickly, in a full stream, and received into a narrow deep vessel. Conversely, exposure, as by a trickling stream, into a shallow vessel, hastens coagulation, and thus prevents these results. Besides these deviations in the process and product of healthy coagu- lation, inflammatory blood is found to have undergone certain alterations in respect of chemical composition. Its constituents, no less than their properties and endowments, are perverted. Becquerel and Rodier enu- merate the following alterations in the blood of acute phlegmasia?:— 1. An increased proportion of fibrin. 2. A decrease of globules. 3. A decrease of albumen of the serum. 4. An increase of fatty matters. 5. A decrease of soda and soluble alkaline salts. In point of practical interest, the importance of all these chemical changes appears to concentrate in the influence they exercise on the sepa- ration of the fibrin, and its coagulability in a free state. Alkaline salts in excess are well known to retard coagulation, and a * Op. cit., p. 335. INFLAMMATION. 35 decrease of the soda and soluble alkaline salts will have the opposite effect. Less time than usual is then allowed for the blood-discs to subside, and so far the formation of the buffy coat is not promoted. An increased proportion of fatty matter will probably favour the early separation of pure fibrin, by inducing it to rise with such matter to the surface (of the blood drawn), and leave the red discs below. A decrease of the albumen of the serum will have a similar effect, by directly diminishing the specific gravity of this fluid, so that the blood- discs sink more readily. The mean specific gravity of the serum in the phlegmasiae generally, is estimated by Becquerel and Rodier at 1027-0; and although, according to Nasse, that is about the average in health, yet the specific gravity of serum in inflammations frequently declines below the mean of 1027. And this is due to the proportion of albumen being reduced below the healthy average of 80 parts in 1000, to 73*35, and even as low as to 64-84. It was formerly stated by Gendrin* that the albu- men rose to about twice its proportion above the standard of health. The decrease noted is in a direct ratio to the increased proportion of fibrin. So also the blood-discs decrease in quantity proportionately to the in- crease of fibrin (Simon), and this reduction will facilitate their complete separation—the more so, since, by undue aggregation of the discs, their com- bined specific gravity preponderates even more than they do individually. Lastly, the increased proportion of fibrin above the average of two to two and a half parts in 1000 of blood, contrasting as it does with the reduced proportion of blood-discs, is the culminating point in favour of a clot being formed of pure fibrin; and this increase, and corresponding formation of the buffy coat, was noticed by Andral and Gavarret to rise as high as ten parts in 1000 of blood drawn, in acute articular rheu- matism, and in pneumonia. The source of this additional proportion of fibrin is doubtful. Simon suggests that the blood-discs are transformed into fibrin, and in conformity with an acknowledged physical law, that as textures waste in proportion to their functional activity, so therefore the blood-discs disintegrate more abundantly in inflammation—owing to their function as bearers of oxygen, to the various textures being overtaxed, in the more frequent transmission of these discs through the lungs, by accelera- tion of the blood's circulation. The flotilla of oxygen-laden cells perishes seriatim from overpressed service, and their wrecks are converted into fibrin. Simon's statement that the discs decrease in quantity propor- tionately to the increase of fibrin, harmonizes with his theory; but, against it, Becquerel and Rodier urge that this destructive change ought to take place whenever the circulation is accelerated, and therefore when- ever fever exists. Yet an increased proportion of fibrin is not found in other fevers accompanied with an accelerated circulation. Is the excessive fibrin transformed albumen ? Probably similarity of composition alloAvs of such transformation ; and certainly, as the albumen diminishes in quantity, so does the proportion of fibrin increase. Of this metamorphosis we know neither the cause nor the mechanism. (Becquerel and Rodier.) Summarily, the coagulation of inflammatory blood—when drawn and fresh—amounts generally to this : the blood-discs, having an undue ten- dency to aggregate, and the net they form an undue power of contracting, * Hist. Anat. des Inflammations, 1826, t. ii. n 2 36 GENERAL PATHOLOGY AND SURGERY. more speedily sink in serum, normally of less specific gravity than the discs individually, of still less than the shrunken nets of discs ; and that this separation of the discs (before coagulation of the fibrin) is facilitated by their reduced number, and by diminished specific gravity of the serum itself. The fibrin then coagulates free of blood-discs, at least in its upper portion, and rises to the surface of the serum, its ascent being probably aided by admixture with the free and floating fat. Such is the coagulation of a sample of inflammatory blood, such the process that sample after sample of inflammatory blood undergoes. It might therefore be inferred that the whole mass of blood, when subject to the influence of inflammation, is ready to undergo these changes, and that it would present the same alterations of chemical com- position if withdrawn from the living body. But does the exalted tendency of the blood-discs to separate, and consequently of the fibrin to coagulate in a free state, prevail in the living body, and affect the whole mass of blood ? This question is highly important; for the nutrition of every part of the body, beyond that which is inflamed, must be modified by excess of fibrin in the blood—hyperinosis, and by its undue separation and coagulation. A blood-crasis bordering on the inflammatory encourages nutrition: a further degree of the same condition of blood encumbers this process with superfluous material. The former is a salutary pro- vision to meet the exigencies of nutrition,—in growth and repair ; the latter, an oppressive compulsion to overgrowth, or at least to an OA-er- flow of the redundant nutritive material. Behold, then, a reparative power ; behold an impending evil. The question proposed is at present open to much, very much, further inquiry. Pathology of Inflammatory Fever.—The alterations of the blood, in connexion with inflammation, proceed apparently from the persistent local determination of blood, coupled with the increased productiveness and destruction of the textures. The increased proportion of fibrin ; and the increased tendency to coagulation, and to separation and contraction of the fibrin in a free state, forming the buffy coat; are both commonly proportionate to the extent of the inflammation, and its duration in an active state. Under similar circumstances of nutrition, the same blood- conditions are induced in a greater or less degree; as during pregnancy, when the uterus is growing; and the buffed appearance of the blood is readily induced by inflammation in fast-growing children, in Avhom also the plastic products are then unusually copious. Inflammatory Fever was formerly supposed to arise from the increased proportion of fibrin in the blood, or hyperinosis, as the cause of febrile excitement of the circulation, and the other functions involved. Hunter advocated this interpretation of inflammatory fever, and he gave cases which as tested by venesection, seemed to support it. But, the recent results of chemical analysis indicate that inflammatory fever may possibly be absent with hyperinosis, or present without it; and they certainly prove beyond doubt that the degree of inflammatory fever cannot be measured by the amount of hyperinosis. MM. Becquerel and Rodier estimate the increase of fibrin in various diseases to range from the healthy average of three to ten parts in one thousand of blood; and that a slight increase from three to five takes place in chlorosis,' in certain cases of scurvy, more especially when it assumes the chronic form during INFLAMMATION. 37 pregnancy, and in erysipelas of the face; yet surely the two first men- tioned diseases are not inflammatory, nor are the ordinary constitutional symptoms of pregnancy those of inflammatory fever. On the other hand, a diminished proportion of fibrin below the average of three in one thousand was noted in scarlet fever, small-pox, and measles; but the ordinary type of these fevers is inflammatory in a high degree. Lastly, when present, the degree of this fever does not correspond with the amount of hyperinosis. A great increase of fibrin up to ten in one thousand ^ was noticed in acute articular rheumatism, in pleurisy, and pneumonia; and a proportion varying from five to ten was also found in peritonitis, bronchitis, and severe erysipelas of the face—diseases which are accompanied with at least as high a degree of inflammatory fever as pleurisy or pneumonia. The foregoing facts and considerations compel us to attribute the accompanying inflammatory fever to some other source than the blood; and the only other bond of sympathetic connexion between the heart and inflamed part is the nervous system. Many years since, Abernethy suggested this channel of communication,* and subsequently, Travers pointed out the agency of the nervous system, and drew the distinction between nervous excitement alone and inflam- matory fever. Although he attributes this fever to excitement of the circulation from hyperinosis, yet he observed that the first morbid im- pression Avas upon the nervous system, and transmitted by the nerves of the part injured or inflamed to the nervous centre, and thence to the organs of circulation. In proof thereof, Travers urges the priority of nervous excitement in the development of inflammatory fever. " The premonitory symptoms—viz. headache, lassitude, disquietude, nausea, chilliness, and rigor are indications of the more or less troubled condition of the nervous centres; to these the alterations in the measure and force of the circula- tion, the permanent and sensible changes upon the internal and external surfaces, and their secretions, succeed—viz., quick pulse, hot skin, dryness of the mouth and fauces, furred tongue, vitiated and scanty secretions,"I &c. I have italicised two of these words in order to bring out the force of this paragraph. Nervous excitement may stop short of inflammatory fever, or may be followed by, and remain associated with, excitement of the sanguiferous system, and either element may then predominate. Thus, " irritation may be a symptom of fever, as fever may be an effect of irritation; but they are originally and essentially distinct forms of disease, and either may exist in the absence of the other.''! Certain of the nervous phenomena which precede and accompany inflammatory fever are difficult of explanation. I allude more particu- larly to inappetency and thirst. Healthy hunger and thirst are .now generally allowed by physiologists to be sensations expressing correspond- ing requirements of the system, rather than proceeding from conditions of the stomach. "These sensations," observes Dr. Carpenter,§ "bear no constant relation to the amount of solid or liquid aliment in the stomach, Avhilst they do correspond with the excess of demand in the system over the supply afforded by the blood; and they abate by the introduc- * Constitutional Origin, &c, of Local Diseases, 1824, p. 3. t Physiology of Inflammation, 1844, pp. 62-63. X Constitutional Irritation, 1826, p. 493. § Principles of Human Physiology. 38 GENERAL PATHOLOGY AND SURGERY. tion of the requisite material into the circulating blood, even though this be not accomplished in the usual manner by the ingestion of food or drink into the stomach." Agreeably to this physiological provision, inflammatory fever should be attended with hunger, rather than inap- petency. Albumen is the pabulum most extensively demanded by the tissues for their support, and its proportion in the blood declines con- siderably during inflammation; yet this deficiency is accompanied with the loss of appetite. Again, the secretions are suppressed, and water, therefore, retained in the blood; yet this excess is attended with inces- sant thirst. Further investigation is needed to clear up these anomalies. All the other phenomena Avhich I have enumerated as emanating from the local irritation spreading through the nervous system, are symptoms of excitement mingled with exhaustion. The sympathetic fever—not inaptly so called—thence arising, is said to have similar types; the sthenic, denoted by forcible action of the heart, and a strong, hard pulse; the asthenic, pronounced by feeble, and rapid action of the heart, and a quick, weak, perhaps irregular pulse. But, after all the distinctions that have been drawn between these types, they are seldom well defined in Nature. Daily circumstances will modify the character of inflammatory fever during its course in the same individual. Does the temperature of the body rise during this fever ? Dr. Thom- son states that it ranges from the low extreme of 94° up to 107° Fahren- heit. This is partly due at least to suppression of the perspiration, and, therefore, the retention of that heat which would otherwise pass off by evaporation from the skin. But the excited nervous system probably contributes to the production of heat. Sir B. Brodie's experiments* show that if the encephalon be removed, the body speedily loses its temperature; a doctrine subsequently confirmed by the experiments of MM. Le Gallois and Chossat. Certain pathological observations also lead us to infer that the loss of nervous influence in any part is accompanied by a loss of temperature there.J On the other hand, the production of increased heat is attributed by Simon to chemical changes in the textures of the inflamed part, and in the blood, and thence in all blood-supplied textures. This chemically changeful state of the blood and textures, with the evolution of heat, are, by the same author, said to constitute inflammatory fever; and that its symptoms are those of this greater heat and change. Thus far respecting the pathology of inflammatory fever, and its origin from the local irritation of inflammatory swelling. But does this fever arise exclusively from inflammation ? It has been alleged that febrile symptoms may precede the local, as in all internal inflammations arising from external cold. To determine this question, take, for example, pneumonia. In most cases, inflammation of the pulmonary texture is consequent on the intro- pulsion of blood by exposure to cold. The superficial blood-vessels con- tract under the influence of cold, the blood retires from them, and the vessels of internal organs become surcharged or congested. The lungs, in their connexion with the whole pulmonary circulation, are especially liable to be the seat of congestion. The heart, overtaxed, fails, for a time at least, to propel the blood through the distal pulmonary vessels, as it also fails to force the blood through the more distal systemic veins * Physiological Researches, 1851, repub. from Phil. Trans. t See Med.-Chir. Trans., vol. vii., H. Earle ; also, Human Physiology, Dunglison, 7th edit., vol. ii. p. 238. INFLAMMATION. 39 leading to the surface of the body; the pulmonary veins become engorged with blood, stagnant, or nearly so. By-and-bye, the heart arouses, as it were, from its lethargy, and makes an effort to restore the systemic circulation, and to clear the pulmonary veins of their superfluous blood. This is reaction, attended with a glow of returning warmth and colour; and, simultaneously, determination of blood through the lungs. Reac- tion does not precede the determination of blood, and if it advance only so far as to restore the average force and frequency of pulse peculiar to the individual, such healthy reaction cannot be called fever; and if it proceed beyond this standard, and the determination of blood become persistent—in fact, inflammatory—even then inflammatory fever arises simultaneously with inflammation, and does not precede it. Then, as in other inflammations, the development of the fever follows the local deter- mination of blood. Causes ; External and Internal,—Exciting and Predisposing. The External causes of inflammation are manifold, but they may all be included under four heads. (1) Mechanical injury or irritation; as wounds, fractures, dislocations; or foreign bodies, introduced into the organism, as grit, portions of clothing, a splinter of wood, a bullet, and parasites, animal and vegetable ; (2) Heat and Cold; (3) Chemical agents which decompose or kill living animal matter, as strong acids, caustic alkalies, chloride of zinc, and other escharotics; (4) Vital irritants, or animal and vegetable poisonous matters, and some mineral poisons; as the venom of noxious animals and plants, cantharides, mustard, capsicum, essential oils, arsenic, etc. Internal causes may be either exciting and immediate, or predisposing, in their operation. Exciting internal causes comprise, the blood, textures, and excretions, of the body, severally, under peculiar circumstances; and morbid products, organized and unorganized. Blood extravasated and decomposing is a foreign body. So also are the various textures, when dying or dead ; in the form of slough of the soft tissues, sequestrum of bone. The various excretions; as urine, faeces, bile, are irritants to the organs which naturally contain them, if such matters be in a state of decomposition ; or if, being themselves healthy, they are extravasated; as urine into the scrotum, feculent matter into the peritoneum. These excretions are peculiarly obnoxious to cellular texture and serous membrane. Lastly, morbid products are apt to excite inflammation. Of deposits, softened tubercle does so in the lungs and other parts; of growths, cancer especially has this effect, the ichorous discharge more particularly being irritating. Calculi are familiar ex- amples of unorganized products exciting inflammation in organs where they occur. For example, a stone in the kidneys provokes nephritis, in the bladder, cystitis. Predisposing internal causes are those conditions which may constitute inflammation, only in a lesser degree; or short of, though bordering on inflammation. But the predisposition differs according to the nature of the cause which excites inflammation. Thus, an ex- cited state of the vascular system favours the production of inflamma- tion from local irritation; whereas, a depressed state of the vascular system favours the development of inflammation from exposure to cold. It is not easy to refer an inflammatory predisposition to any one element of inflammation ; but an approach to certain illustrations of* their 40 GENERAL PATHOLOGY AND SURGERY. respective influences is exhibited by the inflammation of different parts, wherein one or other of these elements predominate. Thus, tissues whose reproductive poAver is greatest, and which are commonly, also, most vascular, are prone to inflammation; as for example, the skin compared with fibrous or tendinous structures. So also, tissues Avhose productive power is temporarily exalted, are ready for inflam- mation ; as during the growth of the body in childhood and youth. The more vascular organs are similarly inclined; the lungs, for example, as compared with most other organs. The condition of the blood is specially influential; rheumatic and gouty inflammations are ever impend- ing when an excess of lactic, or of lithic acid respectively is in circulation. Thence the predisposing influence of constitutional conditions generally, most of which are blood diseases manifested by various local inflamma- tions, and ever ready to recur—as secondary syphilitic diseases of the skin and other parts, scrofulous affections of the bones, skin, and other textures. Other blood conditions predispose, as unquestionably, to local inflamma- tions ; but they require for their development the co-operation of external exciting causes, in each case peculiar, relatively to the special condition of blood, which is thereby brought into action. All the infectious and eruptive fevers are of this kind. [P. p. 310 et seq.] Predisposition through the influence of the nervous system is evoked by nerve injuries, the operation of which in producing peripheral inflam- mation is thus generalized by Simon : " A part deprived of sensibility becomes specially incapable of protecting itself against mechanical and chemical irritants, and accordingly inflames—e.g., the urinary bladder, sub- ject to the action of retained urine, in paralysis. A part injured in respect of its innervation, is likely to suffer some circulatory disorder, with corre- sponding disturbance of natural temperature, and proneness to inflam- mation." The co-operation of all these elements will render the predisposition complete, and almost give rise to inflammation. Thus, the functional activity of any organ, implying the concurrence cf all the conditions essential to nutrition, in excess; such activity is accompanied with a pro- portionate proclivity to inflammation—as in the mammary glands, after parturition when lactation commences, and during its continuance, or the ovaries at the period of menstruation. The operation of inflammation itself, as an internal cause, is both local and constitutional. Locally, inflammation operates by extension, continuously, in the tex- ture or organ affected; contiguously, to parts adjoining ; or, by transference (metastatis) to a part remote from that originally affected, the inflamma- tion then subsiding. Continuous extension is witnessed in the progress of inflammation along the skin or mucous membrane—as in erysipelas, and the sore throat of scarlet fever. Contiguous extension is illustrated by ulceration of the articular carti- lages of any joint, consequent on caries of the adjoining head of bone, or on synovitis. Thus also ostitis supervenes on periostitis ; cellulitis on in- flammation of the skin, and conversely. Taking internal organs, from the head downwards: meningitis is succeeded by cerebritis; scrofulous and purulent ophthalmia, by inflammation of the cornea and deeper textures of the eye ; laryngitis, by inflammation of the subcel- lular texture and oedema glottidis; gastritis, enteritis, cystitis, and metritis, respectively, may extend to the peritoneum, giving rise to peritonitis. INFLAMMATION. 41 The transference of inflammation is exemplified by orchitis supervening on the sudden suppression of gonorrhoea. Such then is the general operation of Inflammation locally; constitu- tionally, its operation as an internal cause, was traced in the origin and development or the pathology of inflammatory fever. Course and Terminations.—Inflammation may proceed to either of 'four Terminations; Resolution, or disappearance; Effusion, or lymph- production ; Suppuration, or as pus-formation ; Ulceration and Gangrene, or death of texture. Excepting the first of these terminations, that of reso- lution or simply cessation of inflammation, the line of demarcation between each of the remaining three modes of termination, is indistinct, and they are commonly more or less combined. A more definite line of distinction may be drawn between them, by regarding the course of inflammation in reference to its two principal constituent elements; increased productive- ness, and increased destruction, of texture. According as one or other of these predominates, so may we associate therewith the remaining ter- minations of inflammation respectively; as effusion, and suppuration ; ulceration and gangrene. 1. Resolution.—Inflammation may subside and terminate without any permanent structural result. The redness fades away, the part recovers its healthy temperature, slight swelhng if perceptible subsides, and exalted sensibility or pain ceases ; while any inflammatory fever passes off. This is resolution ; a termination of inflammation by the concurrent cessation of all the elements of this process; and consequently, the cessation of its local and constitutional manifestations. 2. Productiveness may predominate; then, Inflammation proceeds to Effusion, or, perhaps, Suppuration; an increase of new material in the part, beyond the small proportion which necessarily attends inflammation. Liquor sanguinis appears, consisting of coagulable lymph and serum. In the latter constituent, the proportion of albumen and of salts is increased ; but of these there is a larger proportion of chloride of sodium and phos- phates than in the blood. Three conditions of lymph may be distinguished by tolerably well marked structural characters : the fibrinous and corpuscular of Paget, and a transition condition, consisting of both fibrils (filaments) and cells, the latter predominating. Similar susceptibilities of organization represent the varieties noticed by Dr. C. J. B. Williams, as the euplastic, aplastic, and cacoplastic. They differ also in point of vascularity, in the course of their development. With these typical conditions of structure are associated tolerably definite physical properties: Fibrinous or Euplastic lymph—transparent, nearly colourless, and tenacious. Corpuscular or Aplastic lymph—opake, yellow, diffluent. Transition condition or Cacoplastic lymph—opakish, yelloAvish, and less tenacious than the euplastic type. These characters are more clearly contrasted when placed in juxtaposition. LYMPH. Fibrinous, „. . , I Transparent. Physical \ Colouriess. properties j Tenacious. Trausition condition. Opakish. Yelbwish. Tenacity less. Corpuscular. Opake. Yellow. Diffluent. ( Fibrils. Structure < Celis. ( Bloodvessels. Ex. False membranes. Ex. Cells. Fibrils. Bloodvessels fe Cirrhosis. Cells. Granules. w. Bloodvessels absent. Ex. Pus. 42 GENERAL PATHOLOGY AND SURGERY. The qualities of lymph are certainly most obvious when it is effused from simple membranes, as the serous—for instance, pleuritic effusions; while the more complex structure of skin and mucous membranes retard its separation, and modify its properties by the admixture of their own secretions. Hence the varied products of skin diseases, and those discharged from the gastro-intestinal canal, the urinary and pulmonary passages. Nevertheless, the peculiarities I have mentioned are fully confirmed by the observations of Mr. Paget, who carefully examined the materials exuded in thirty cases of blister from cantharides. It will be desirable first to describe, more particularly, the elementary products of Effusion, including Suppuration ; and then, their apparent source and mode of production, or the pathology of Effusion. Effusion—Products of Inflammation.—(1) Coagulable lymph is more or less tenacious and at first transparent, but it acquires a slightly opake yellow colour. It is produced in the form of minute villi. This appear- ance is best seen on free surfaces which are least subject to motion or pressure; as between convolutions of the intestines in peritonitis; between the lobes of the lungs in pleurisy; and about the base of the heart in pericarditis. But wherever serous surfaces are in contact and play upon each other, the ductile lymph is drawn into threads or plastered into films; as on free portions of the pericardium and pleura, and on the parietal aspect of the intestines. Coagulation having taken place, coagulated lymph is somewhat solid, though still retaining its tenacity and opakish yellow colour. Its organi- zation, in this its simplest condition of structure, is that of fine fila- ments, interwoven in various directions; as in the buffy coat of blood. Fig. 1.* These filaments are formed apparently by the linear union of molecules, are homogeneous, and from niorrto^ of an inch in diameter. (2) Cells or corpuscles form in coagulable lymph, and are found interspersed among the molecular formed filaments, in coagulated lymph. These cells contain each from three to eight granules, the diameter of which equals that of the filaments. The cells themselves range in size from -j-^j. to -^^ of an inch. (See Fig. 1.) They have been named plastic by Dr. Bennett, because occurring so often in plastic lymph; and also named * Molecular fibres and plastic corpuscles, in simple exudation on a serous surface. Above are corpuscles after the action of acetic acid. 250 diam. (Bennett.) INFLAMMATION. 43 pyoid by Lebert, from their general resemblance to pus corpuscles. But neither Avater nor acetic acid much affect these plastic cells. Cells of this kind undergo development. By elongation, they assume an oat-shape; prolonged yet further in opposite directions, they are attenuated into filaments, — forming fibre-cells. Thence is produced fibro-cellular, or connective, tissue,—generally, the highest state of organi- zation of inflammatory effusion. (Fig. 2.) Fig. 2. Blood-vessels are found in organized inflammatory lymph, and possibly in coagulated lymph, but they do not appear to be formed in it; they project into the new tissue from the structure on, or in, which it is placed. The vessels are formed by the same process of sprouting, coales - cence, and construction of loops, as in granulations. Lymphatics were discovered by Schroeder Van der Kolk* in false membranes. Nerves have been twice seen by Virchowf in adhesions; one of the pleura, the other of the peritoneum—between the liver and diaphragm. False Membranes are formed on the inner or free surface of serous, and of mucous membranes; as in pleurisy, pericarditis, and peritonitis; in croup, and dysentery. Such membranes consist of inflammatory-lymph, which has undergone more or less development; and on serous surfaces,, it may reach the state of organization just described, that of fibro-cellular tissue, supplied perhaps abuudantly with blood-vessels. The physical characters of false membranes vary according to their more or less high degree of organization and vascularity; the membrane formed is either pliant and yielding, or tough and unyielding. Adhesion is apt to take place when the opposed surfaces of a serous cavity lined with inflammatory lymph, meet together. Similar adhesion may take place in wounds, or under other circumstances. Any such re- sult of inflammatory lymph-effusion is sometimes referred to adhesive inflammation. Other and more highly-developed tissues are reproduced. Many such results of inflammatory lymph-production are adduced by Paget. * Spec. Anat. Path, de Vasis novis Pseudo-membranarum, 1842. f Wiirzburg. Vtrhandlungen, i. 144. 44 GENERAL PATHOLOGY AND SURGERY. Adipose tissue may be formed, if not directly from inflammatory lymph, yet in the fibro-cellular tissue of completely organized adhe- sions. Elastic tissue is sometimes abundantly formed in the adhesions developed from inflammatory lymph, and particularly in those of the pleura. Epithelium covers the surfaces of well-formed adhesions. Fibrous tissue is produced from the development of inflammatory lymph, inter- stitially deposited in any fibrous tissue; as in ligaments, capsules of joints, &c. Bone is often formed, either as a late transformation of in- flammatory lymph, which had become organized into perfect fibrous tissue—e.g., osseous plates in false membranes of the pleura, and in those of the pericardium, which plates are not true bone ; or new bone appears in the form of ossific deposits, connected with inflamed bone or periosteum. Cartilage is possibly formed in chronic rheumatic arthritis.* This new cartilage is prone to ossify. Lymph-effusion may undergo absorption ; or if persistent, its opera- tion may be either destructive, or reparative and constructive, and accordingly, unfavourable or favourable to the function of the organ or texture affected. Destructive consequences of lymph-effusion are illustrated by many organs. The heart may be shackled by tags of false membrane, which continually restraining the action of this organ, at length induces its hyper- trophy ; a compensatory provision of increased structure for extra con- tractile power. Or the heart may undergo compression by great thickening of the cardiac reflexion of the pericardium, in consequence of the interstitial deposition of lymph therein, and thence the organ becomes atrophied. The lungs may suffer in like manner, either way. Perito- nitis is apt to agglutinate the abdominal viscera into one mass. Within the substance of parenchymatous organs, contractile lymph being de- posited, they become stuffed, consolidated, and sometimes atrophied and granulated. Such are old hepatized lungs, cirrhosed liver, and granular kidneys. Strictures are liable to form around canals ; as the oesophagus, rectum, and urethra, narrowing or closing them and proportionably interfering with the functions of these passages. Eventually displace- ments of moveable viscera are wrought by the slow contraction of lymph- deposit, overcoming the struggle of function to recover the right adjust- ment of parts. Analogous mischief may happen to the mechanism of the limbs • joints become stiffened by firm fibrous anchyloses, the tendons are bound in their sheaths, and the fasciae agglutinated, in chronic rheumatism. This fettered condition of organs, their consolidation and atrophy, obstruction, and displacements, are the principal destructive results of lymph-effusion. On the other hand, its operation is not unfrequently reparative, to reinstate an old function, or constructive, to fulfil a new and useful purpose. The reparative power of adhesive inflammation is manifested by the healing of incised wounds in those cases where the effusion of lymph is induced by inflammatory hyperaemia. The repair of simple fracture and of simple dislocation, when reduced, is an analogous process, and commenced probably by inflammatory hyperaemia consequent on the * Trans. Path. Soc. Lond., vol. iii. 1851. By W. Adams. INFLAMMATION. 45 injury. So, also, Avounded arteries are permanently closed by adhesion of an inflammatory character in some cases; and the healing of ligatured arteries is certainly effected by adhesive inflammation, which seals the divided coats of the vessel above and below the line of ligature. Pene- trating wounds of the thorax and abdomen, implicating the viscera, afford ample and varied evidence of the reparative power of adhesive inflamma- tion. Wounds of the lung are healed by adhesion of the pulmonary pleura consequent on inflammation. Wounds of the abdominal viscera are healed in like manner wherever the peritoneal investment extends ; and the visceral reflexion of the peritoneum is very apt to adhere to the parietal reflexion of this membrane opposite the external wound. These results are explained in describing the healing of wounds of the abdomen and thorax respectively. In certain cases the peritoneum' is purposely injured by the surgeon, so as to establish adhesive inflamma- tion. This constitutes the radical cure of hydrocele and that of hernia ; the former being accomplished by a stimulating injection ; the latter by long-continued pressure with a truss; or the radical cure of hernia may be accomplished on the same principle by the successful operation re- cently introduced by Mr. Wood. Lastly, among the most familiar ex- amples of beneficial adhesive inflammation, I may mention the well-knoAvn fact that foreign bodies, long imbedded in the living tissues, thus become enclosed in organized lymph, and their presence rendered comparatively harmless. An encysted foreign body is quiescent. Reviewing these and similar results, there appears to be sufficient reason to justify Hunter's view of the use or purpose intended by ad- hesive inflammation. " It may be looked upon as the effect of wise counsels, the constitution being so formed as to take spontaneously all the precautions necessary for its defence; for in most cases we evidently see that adhesive inflammation answers wise purposes." In conformity Avith this design, Ave observe inflammatory adhesion preventing suppuration, or confining its extent—in the pleura, in the peritoneum, occasionally ; in the synovial capsules, and determining the boundary of an ordinary abscess; beyond which circumscribed limit, in any case, the pus formed cannot pass. Then, again, the same process prepares the way for the discharge of pus, without infiltration of the textures during its passage or escape into any natural cavity through which it may traverse. Any collection of matter having become circum- scribed—as an abscess—by the deposition of inflammatory lymph, is gradually conducted through the surrounding textures at their most yielding point; the pathway having been previously paved securely for this purpose by their adhesion. The pus is still watchfully circum- scribed during its passage, until at length the contents of the abscess are discharged. An abscess is thus advantageously opened by Nature. Ab- sorption makes the channel, and in the direction of least resistance ; but adhesion makes its banks secure. With this precaution a collection of matter is safely conveyed from a great depth in the body, and by an otherwise dangerous route. Witness the evacuation of pus from the pleura (in empyema), through a large and pendulous mamma. Adhesions of other serous surfaces favour the escape of matter. When a student, I once saw an abscess of the liver which pointed and threatened to burst externally, but which eventually relieved itself by perforating the dia- phragm and right lung successively, a continuous expectoration of pus 46 GENERAL PATHOLOGY AND SURGERY. being provided for by adhesion of the pleura where perforation had taken place. Sometimes, by a similar provision, an abscess of the liver dis- charges itself externally, or into the stomach, the duodenum, or the colon. An abscess of the kidney will also thus communicate with the colon ; and an abscess in the right iliac fossa will be emptied into the colon, caecum, or bladder. These are instances of a new mechanism being constructed for some new, but perchance temporarily useful purpose, which is perhaps less frequently the intention of reparative inflammation than that of perma- nently restoring some lost part, and of thereby reinstating a former function. (3) Exudation corpuscles are round or irregular little masses, having a dark and mulberry looking appearance, under the microscope. Their size is about i Q\ 0 to T4^ of an inch in diameter. They consist of granules v aggregated together, and sometimes enclosed in a cell-membrane; hence they are named also compound granular corpuscles. (Fig. 3.) Within each of these corpuscles is seen a round trans- parent nucleus, varying in size from -6 ^ 0 to ^JL^. of an inch in diameter. The granules vary from 12^00 to -g-oVo" 0I"an incn- They are fatty. Acetic acid does not affect the cells or masses; but they dissolve immediately in ether, and disintegrate under the influence of potash or ammonia. (4) Pus is a fluid having peculiar physical characters; an opake greenish-yellow colour, diffluent or creamy consistence, faint odour, and an average specific gravity of 1030, but varying considerably, from 1020 to 1040. All the characters of healthy pus differ considerably in the many diseased states of this product. This fluid consists of a serum in which are sus- *ig. 4.f pended an innumerable multitude of corpuscles. (&§ /g~>^/~\ (Fig. 4.) They are spherical, somewhat granular- §& ^~^-S^y looking cells, from ^-^ to -g^ of a line in diameter ; /5f 2f "?.(®)aa an^ consisting of a cell-membrane, enclosing granular or molecular matter, and a nucleus situated, gene- rally, on the (interior of the) cell wall and adherent. It varies in size from -g-^ to ^Lg- of a line across, and consists of two, three, or four granules aggregated together. These secondary nuclei are round, oval, sometimes elliptical. The whole cell,—its membrane, and contained molecular matter and compound nucleus, are albuminous. Water distends these corpuscles, and acetic acid dissolves the molecular matter, perhaps also the cell-membrane, and by loosening or breaking up the nucleus, displays its compound structure. (See Fig. 4, the five transparent cells.) Pus has been analyzed by Giiterbock, Valentin, Golding Bird, Wood, Von Bibra, and Wright, with unsatisfactory results. J I take the follow- ing particulars from the most recent work§ of authority on this subject. * Granular cells and masses from cerebral softening. (Bennett.) t Pus-corpuscles, as seen in healthy pus ; the fine transparent cells are as seen after the action of acetic acid. (Bennett.) X See Pathological Chemistry. 1853. By Becquerel and Rodier. Translated by S. T. Speer, M.D. 1857. P. 529. § Chemistry in its Relations to Physiology and Medicine. G. E. Day, M.D. 1860. P. 221. INFLAMMATION. 47 Pus-serum is a clear, colourless, or very faintly yellow fluid, having a weak alkaline reaction, and coagulating by heat into a dense white mass. Albumen is its chief constituent, in proportion from 1.2 to 3.7£. Fatty matter is extracted by ether, and it consists of olein, margarin, oleic and margaric acids, and cholesterin. These fatty matters vary from 2 to 6% of the Avhole fluid, of which proportion, cholesterin alone often reaches to 1£. Mucin, pyin, casein, chondrin, glutin, and leucine, are occasional constituents. The solid constituents of this serum range from 14 to 16$, of which from 5 to 6$ are mineral, and the soluble salts are to the in- soluble as 8 to 1. Of the former, chloride of sodium is most abundant, being three times more so than in the serum of blood. The soluble phosphates range from 3 to 10$. The insoluble salts are phosphates of lime and magnesia, with a little sulphate of lime and peroxide of iron. Certain incidental matters may be present in pus, as in any other exuda- tion ; namely, bile-pigment, the resinous acids of the bile, urea and sugar. Pus is seldom found pure, but associated with various ingredients, the debris of surrounding textures, and mixed with secretions. Healthy or laudable pus may thus become serous, mucous, sanguineous, strumous, cancerous, &c. Or pus may be specific, as the syphilitic pus, vaccine matter, pus of porrigo, of glanders, &c. The formation of exudation and pus corpuscles is, probably, as follows. Granules aggregate and constitute a compound granular mass. An investing cell-membrane may gather around such a mass, as a nucleus. Both these are forms of the exudation-corpuscles. Partial liquefaction of the peripheral granular matter of a cell-enclosed mass, may give rise to a pus-cell, with its compound granular nucleus. The chemical metamor- phosis of cell-contents, or the substitution of albuminoid for fatty granules, is not understood. But the structural relation of pus-cells to exudation corpuscles, would seem to be a degenerative transformation. Several such transformative conditions of exudation corpuscles are repre- sented in Fig. 3. Pus-cells are also structurally related, in some way, to those of mucus and chyle ; and the whole series of cells—including exuda- tion corpuscles—would seem to have a family relationship to the pale corpuscles of the blood; as being rudimentary states of these cells by arrests of their development. The products of Inflammation are usually found associated; but one or other so far predominates, in different textures or organs, as to give its own structural character to the deposit; in cellular texture and parenchymatous organs, as the lungs, the product is chiefly granular matter and exudation corpuscles; in or On mucous membranes, chiefly pus; on serous membranes, chiefly coagulable lymph. Pathology of Effusion and of Suppuration.—Analogy would lead us to expect a general resemblance between the processes of healthy nutrition and inflammatory effusion ;—that the composition and vital condition of the blood will predispose to the formation of certain products; and that this process is affected by the degree of inflammatory hyperaemia, and by the force of the general circulation; that it is regulated by the nervous system ; and is completed by the secretory or the formative power of the inflamed structure. How far does all this anticipation accord with knoAvn facts ? First as to the condition of the blood, in its relation to inflammatory effusion.' Serum exudes from the engorged vessels, and fibrin therefore, 48 GENERAL PATHOLOGY AND SURGERY. may also escape in a fluid state. But inflammatory blood superabounds with fibrin, and consequently this state will tend to deposit it more freely. The liquor sanguinis effused, will be, for the most part, fluid fibrin; and such is the typical character of coagulable lymph, which represents the first product of inflammation, before the formation of filaments, or of exudation, or pus-corpuscles. It is that Avhich appears in the first instance on blistered surfaces, as demonstrated by Mr. Paget's observations. The quantity of liquor sanguinis, and therefore of fibrin, effused, is further regulated by the degree of hyperaemia, aided by the force of the general circulation. Virchow denies this explanation of fibrin-production. He argues* that nobody has ever been able to prove the affirmative experimentally; that " nobody has ever been able, by producing a mere change in the force of the current of the blood, to induce the fibrin to transude directly, as it is wont to do in certain inflammatory processes; for this, some irri- tation is always required." I shall presently recur to the latter clause in this paragraph; but the want of experimental proof that fibrin is pro- duced in an inflamed part, by the force of the blood's current, is, I think, compensated by familiar observations quite as conclusive as any experi- ments. When the pulse is strong and hard, the blood flows forcibly through unyielding vessels, and tells on an inflamed part; then fibrin is produced abundantly in that part: Avhen again the pulse is rapid rather than strong, and compressible, the blood is misdirected; then less fibrin is found in the part inflamed. The former condition is illustrated by common phlegmonous inflammation, with much fibrin; the latter, by erysipelas, with much serum. This large proportion of fibrin, or of serum, does not, it is true, necessarily accompany only those states of the local and general circulation to which I have referred. The same results may possibly proceed from, and denote an excess of fibrin, or of serum, in the blood; the presence of the blood's circulation in an inflamed part may not be the only cause of a serous or fibrinous effusion : but Avhenever the circulation is active and tense, then there is a tendency to the effusion of fibrin; whenever the circulation is feeble and lax, then a tendency to the effusion of serum. The inference obvi- ously suggested by this invariable sequence is, that a mere change in the force of the blood's current is a cause of fibrinous effusion. It is recog- nised as such in practice. Phlegmon and erysipelas are regarded as representing almost opposite conditions of the circulation. Beyond these sources of lymph-effusion, it is possible that the character of the deposit may be influenced by the nervous system • but the share of its influence, if any, must be determined by future inquiry. Lastly, the structure in which inflammation takes place, may itself exercise some power, either by selecting the fibrin from the blood, thereby inducing its effusion, or by producing it in the inflamed part through metamorphosis of the material effused. In other words, an inflamed structure may possess either a secretory, or a formative power. Virchow adheres to the latter view, and maintains by experimental observations, that irritation induces the effusion of a fibrinogenous sub- stance, which can be converted into fibrin. In proof of the self-suffi- ciency of irritation, Virchow adduces the operation of a blister; that * Cellular Pathology, p. 163. INFLAMMATION. 49 firstly, serum only is yielded, but if the irritation be more violent, a fluid which coagulates. The general doctrine advanced is thus stated : " A patient who produces at a certain point a large quantity of fibrin- forming substance, much of it passes from that point into the lymph, and finally into the blood. The exudation may therefore in such cases be regarded as the surplus of the fibrin formed in loco, for the removal of which the lymphatic circulation did not suffice. As long as the current of lymph does suffice, all the foreign matters which are formed in the irritated part are conveyed into the blood; but, as soon as the local pro- duction becomes excessive, the products accumulate, and in addition to the hyperinosis, a local accumulation of fibrinous exudation will also take place." More consistent with known facts is the operation of a secretory power, by which structures select this or that constituent of the blood as it passes through them, and by which the effusion of that particular constituent is determined. An approach to the proof of this theory is, I conceive, the behaviour of the same blood in different textures. Blood, having the same composition and properties, deposits in one inflamed part much fibrin; in another, rather albumen ; in a third, more fatty matter. In pleuro-pneumonia, for example, fibrin and a large proportion of serum are effused from the inner surface of the pleura; an albuminous matter is deposited in the lung-parenchyma; and pus, in which fat abounds, is more readily secreted from the (bronchial) mucous membrane. These products are known ingredients of the same blood, flowing alike to each of the three structures mentioned, and yet they severally receive a dif- ferent kind of deposit. The inference is, that the particular deposit is selected or secreted by the particular kind of texture. How far this secretory power is a vital property; hoAv far it results from the physical construction of the texture, is an open question. Assuredly the physical consistence and permeability of a part will very much affect its capability of receiving this or that kind of effusion. Probably all the causes of effusion co-operate. The " composition and properties of the blood," the " hydraulic state of the circulation— both local and general," the secretory power of the " structure," and per- haps " nervous influence," are each engaged; and sometimes serum is the prevailing product, sometimes fibrin, as I have explained. This latter soon coagulates, and the effusion, at first fluid, assumes the physical character of a mixed product—partly solid, partly fluid, varying in this respect as either fibrin or serum prevails. Pus is a new product; but its evolution appears to be governed by conditions analogous to those which regulate the formation of other in- flammatory products, and those of nutrition in general. " Secretory power " is in operation, regulated probably by " nervous agency," and determined by the " condition of the blood;" possibly also by the "flow of that blood to the part." Pus has been termed a secretion; and its constant production in connexion Avith certain textures, rather than others, although the blood be the same, plainly indicates that such parts possess and exercise some secretory power. The readiness with Avhich mucous membranes suppurate is well known. Bronchitis, enteritis, and cystitis are prone to induce purulent sputa, faeces, and urine, respectively; indeed, pus has been found on a bougie five minutes only after it Avas introduced into the urethra. Other E 50 GENERAL PATHOLOGY AND SURGERY. textures are far less prone to suppurate. An incision through the skin and subcutaneous cellular tissue probably unites by adhesion, Avithout any suppuration, or pus is not produced for tAvo or three days. Observations such as these tend to establish the theory, first advanced by Simpson,* that pus is a secretion. Certainly it is as much so as cuticle and all other tissues. They are evolved from a blastema, effused from neighbouring vessels; and pus is also the product of a blastema, but which is effused by inflammatory hyperaemia. The doctrine of pus- secretion was likewise suggested by De Haen; and a few years after- wards, Dr. Morgany fully discussed the whole question. BrugmannJ followed Avith a similar view; and at length Hunter§ adopted and sup- ported this secretion theory, without, however, having first suggested it, as is sometimes asserted. The pus-forming power of textures is probably regulated, like other secretory power, by the nervous system. In paraplegia, cystitis usually ensues, and this paralytic cystitis produces purulent urine in a more marked degree than cystitis arising from other causes. Injury of the fifth pair of nerves is followed by suppuration of those parts which they supply. Such cases shoAv the effect of intercepting the nervous influence to a part; but the nervous system exhibits its influence by inflammation and suppuration of a part through sympathy with some irritation in another and perhaps distant part. Mr. Paget refers to a specimen|| where extensive deposits of lymph and pus were found in the testicle of a man whose urethra contained a portion of calculus impacted after lithotrity. Analogous cases are on record. The influence of mental emotion in producing inflammation with speedy suppuration is manifested by the following case,IT and of which there are similar ones. A lady was watching her little child at play, and she saw a heavy windoAV-sash fall upon its hand, cutting off three of its fingers. In a short time the mother also had in- flammation of the corresponding three fingers of her own hand, and in twenty-four hours pus was evacuated by incision. Pus-production is determined very much by the condition of the blood. One would suppose so, judging from the analogy between pus- secretion and other efforts of the secretory power. Certain experiments made by Mr. Paget supply apposite illustrations. They show that the same tissue, inflamed by the same stimulus, and as near as possible in the same degree of inflammation, yields, in different persons, and in whom therefore the blood may be considered dissimilar, different forms of lymph. The inference is obvious, that blood-conditions determine the kind of product which shall be formed, or, as we may say, secreted. I have already noticed this doctrine and these experiments. Blisters raised by cantharides in thirty patients gave sometimes a fibrinous, sometimes a purulent product. It was found that in cases of purely local disease in patients otherwise sound, the lymph formed an almost unmixed coagulum, in which, when the fluid was pressed out, the fibrin was firm, elastic, and apparently filamentous. Whereas, in cases at the opposite end of the scale, such as those of advanced phthisis, a minimum of fibrin was con- * Dissertationes de re Medica, 1722. t Puopoises sive Tentamen Medicum de Puris confectione, 1763. X Thesis de Puogenia, 1785 § Blood and Inflammation, 1794, p. 417 et seq. II Museum of St. Bartholomew's Hosp., Ser. xxviii., No. 55. y Pathology and Treatment of Hysteria, Carter, 1853, p. 24. INFLAMMATION. 51 cealed by the crowds of corpuscles imbedded in it. Mr. Paget therefore concludes that the highest health is marked by an exudation containing the most perfect and unmixed fibrin; the lowest, by the most abundant formation of corpuscles, and their nearest approach, even in their healthy state, to the characters of pus-cells. Has continued determination of blood any influence in producing pus? It has been alleged, that, " such a result is most likely to ensue in complex and highly vascular structures, where the effused matter is retained in intimate contact with the blood-vessels ; hence intensity and continuance of inflammation in the true skin, cellular textures, glands, and most parenchymatous organs, pretty surely lead to suppuration."* And in explanation of this process, it is suggested by the same authority, that, as under the exaggerated " influence of the red-corpuscles (which convey oxygen) on the liquor sanguinis, more of its protein passes into the state of solid deutoxide,—a material fitted for organization and reparation; so we may infer that the excessive degree or continuance of the same action may overdo this change, give chemical properties an ascendancy over the vital powers, and by turning the most recently-formed solid into a fluid tritoxide, may effect a work of separation and destruction, involving the blood in the obstructed vessels, and extending to the albuminous matter of the containing texture." This chemical theory needs no further refutation than the now ac- knowledged fact, that protein itself is a chemical myth, having no existence, and of course therefore incapable of forming a deutoxide, and then a trit- oxide. But what influence does persistent determination of blood exercise, under the circumstances of pus-formation, in complex and highly vascular structures ? If an incision be made when pus is about forming in a large boil, an abundance of solid lymph is seen agglutinating the cellular tex- ture. Pressing as this does upon the vessels which it encompasses, they become, at least partially, occluded. Inflammation being far advanced, "ob- struction" is now added to " persistent determination" of blood. And this obstruction, this solid lymph and agglutinated cellular texture, may extend for some distance, giving the external swelling a broad base. Around the periphery of the solid swelling blood plays freely, yet without pus forming there; whereas, in the centre, first appears a white spot of pus, far removed from the circumferential determination of blood. This afflux of blood goes on depositing fresh lymph, thus enlarging the swelling; while in the midst of the solid lymph and occluded vessels, more and more removed from all such external influence, suppuration proceeds. Per- sistent determination of blood, therefore, only prepares a structure for suppuration ; suppuration itself is an independent process. Consequently, we are not surprised to discover pus in a texture where determination of blood cannot have availed much; as in the centre of a large fatty tumour, itself but ill provided with vessels for its oavh supply of blood; and the freest afflux of blood without suppuration, as in a gouty toe. Signs of Effusion, and of Suppuration.—Inflammatory Effusion is attended with swelling, in consequence of the progressive accumulation of the products of effusion. The nature of this SAvelling may be recognised partly by considering the physical character of the products; liquor sanguinis presenting a SAvelling, at first fluid, but as coagulation ensues, it soon assumes the character of a mixed product—solid and fluid, varying * Principles of Medicine, C. J. B. Williams, M.D., 3d Edit., p. 364. E2 52 GENERAL PATHOLOGY AND SURGERY. as either fibrin or serum prevails. The diagnosis of a chronic swelling of doubtful character, can be completed by puncturing its substance, and if necessary by further examination with the microscope of the very matter effused or the resulting products. Suppuration is announced by a throbbing or pulsating pain, increased heat, redness and swelling. But proceeding as these signs do from in- creased determination of blood—a condition not essential to suppuration —they are not invariably present, or followed by suppuration; the incon- stancy, in either respect, depending on the kind of texture in which inflammation takes place. In any unyielding texture, inflammation is accompanied with a throb- bing pain, without suppuration, necessarily, ensuing; toothache being a familiar example. In a loose parenchymatous texture, which more freely admits the afflux of blood, extensive suppuration may have supervened, without any previous throbbing; as in the cellular texture of the ischio- rectal fossa. Conversely, with regard to increased swelling;—in loose cellular tex- ture, considerable effusion and swelling may have taken place, Avithout suppuration ensuing; while, in an unyielding texture, an abscess forms, without any previous increase of swelling. The diagnostic value of these symptoms is perhaps fairly this; when suppuration does occur, in unyielding textures, it is invariably preceded by throbbing, with increased heat and redness ; and, in yielding textures, by increased swelling. Otherwise these are not constant signs of approaching suppuration. Consequently, they are not absolutely trustworthy as pre- monitory symptoms. But the physical properties of pus confer certain distinctive characters on any soft part in which it is formed. Just as the first effusion of lymph is recognised by a semi-solid swelling, arising from the products—fibrin and serum—into which that lymph has become resolved; so now another product,—fluid, but of creamy consistence, and slightly viscid, imparts a more elastic feel to the swelling. It is the sign of diffused suppuration, and this condition may continue, or a further change take place. Abscess.—Lymph may become deposited so abundantly around the focus of suppuration, as to effectually circumscribe and imprison the pus. The textures, thus encompassed, die, disintegrate, dissolve, and are re- moved by absorption, leaving the pus, more or less pure, in their place. An abscess is formed. The circumferential lymph of this pus-con- taining cavity, assumes, somewhat, the structure and characters of mucous membrane, and acquires a secretory power. It becomes pus- forming, as well as pus-containing; it is a pyogenic membrane. And as it absorbs old pus, as well as secretes new matter, the abscess is gradually concocted or ripens. The Signs are now those of abscess. The throbbing pain, heat, and redness, all the signs of previous active hyperaemia, are mitigated by the yielding resistance of pus as compared with that of partially solid lymph ; unless the matter be confined under any unyielding-texture, such as a fascia, or within bone. But a fluid and fluctuating SAvelling is presented, rather than one having the solidity of coagulated lymph, or the greater elasticity of pus diffused. Like any other structure, pyogenic membrane may lose its functional power ; then, pus-secretion fading, while absorption continues and pre- vails, the abscess dwindles and gradually disappears; or, retaining its INFLAMMATION. 53 power unimpaired, secretion and absorption are, perhaps, equally balanced, and the abscess remains stationary and becomes chronic; or, lastly, acquiring a higher degree of secretory power, pus accumulates, the pyogenic membrane itself grows proportionately, and the abscess enlarges. The pus-secreting sac or cyst, thin and smooth, is gradually transformed into a soft spongy membrane, slightly mammillated, and of a greyish or reddish brown colour, as seen after death. This sac is attached to the surrounding textures loosely or closely. They are detruded and absorbed under constant pressure by the expanding abscess, and thus the area or size of the fluctuating swelling increases. At length—in a variable period, usually before the abscess becomes chronic—absorption of the pyogenic membrane itself begins, under the expansion of constant fluid-pressure. And, generally, in the direction of least resistance the abscess points ; the circumferential tissues undergoing absorption more readily, or yielding more in that direction as the expand- ing force there gains advantage. On the side of the abscess opposite to this thinning portion, the pyogenic membrane, according to Macartney's observations, actually grows thicker, and contracts so as to exercise some degree of expulsive power. A prominent point appears, over which the skin assumes a dark livid tint, and the cuticle is shed in eccentric rings. Here fluctuation is most perceptible. Soon a small slough separates and pus escapes. Thus also in the case of mucous membrane, an aperture is formed; but serous membrane yields with a rent. Distension is relieved, and if the aperture be sufficiently free and dependent, or made so, the matter is discharged or drains away daily, coagulable lymph is effused instead, and forming granulations, it contracts towards the aper- ture, and gradually closes the cavity of the abscess. The residual abscess is now a healing ulcer, and the process of reparation is completed in a period varying from, perhaps, twenty-four hours to days, Aveeks, or months. If contraction be incomplete, the sac of the abscess is brought together only here and there, leaving intervening pus-producing cavities; a multilocular abscess is formed. Or, the cavity contracts into a long narrow channel, lined with a perfect pyogenic membrane throughout its course, and having an obstinate indisposition to heal; a fistula is formed. It is convenient to distinguish a sinus by the absence of these characters. The latter is said to be distinguished from the former, principally, by its having only one opening; a sinus being a long, narrow, suppura- ting canal, opening externally or internally, and having little dispo- sition to heal. But either such canal is an incomplete fistula; as may be fistula in ano. The minute structure of the walls of these passages, the different appearances of their aperture or apertures, and the modes of their formation, are details, for the most part, of little practical importance, or pertain rather to special and regional pathology. Sometimes the process, after evacuation, is unhealthy, and without any tendency to heal. The sac secretes a fetid sanious pus, induced probably by the admission of air or by some constitutional disorder affecting the pyogenic membrane, and the production of granulations is delayed. Or, at a later period, when the abscess is reduced to an ulcer, it, like ulcers arising otherwise, may exhibit an obstinate indisposition to heal. From constitutional causes, chiefly, this ulcer may become indolent, irritable, inflamed, or phagedaenic. 54 GENERAL PATHOLOGY AND SURGERY. The function of pus may be inferred from its relation to the process of healing by suppurative granulation, in a healthy ulcer or sore. The cells of pus are either degenerate or immature granulation-cells. It the former, pus represents the superficial portion of organized granulation-matter, which, having lived its time, passes off, just as the outermost epithelial cells are shed. If immature granulation-cells, pus represents the super- fluous portion of organizable granulation-matter, which never reaches maturity. This is the more probable interpretation. Compare pus- cells—as unaffected by acetic acid—(fig. 4, cells to the left), with granu- lation-cells (fig. of granulation-structure, in this work), and their great similarity or identity will be obvious. As immature granulation-cells, pus ceases to be secreted when the granulations come to the level of the skin, for then, the ulcer being filled up, no more organizable material is needed. Suppuration may thus be associated with a restorative or reparative pur- pose ; as in the closing of an abscess after evacuation of its contents, and in the healing of open wounds, compound fracture and dislocation. The situations where abscess originates are regulated, it would seem, very much by the different kinds of texture. Rarely, if ever, is abscess formed in fibrous or cartilaginous tissues, nor within any serous mem- brane. The situations where abscess may be found, are very various. It may have extended from its seat of origin to another, and perhaps distant, locality. Abscess by translation, as any such extension is termed, somewhat inaptly, is favoured by various circumstances; by the difficulty with Avhich pus produced in certain parts, finds its way to the surface; by the comparative facility with which it travels to other parts ; by slow progress of the abscess, allowing opportunity for its extension; and by special circumstances conducing, which are peculiar to each case. Examples of such abscess occur chiefly in connexion Avith the spinal column. Taking them from above downwards; abscess arising from disease of the cervical vertebrae, may present directly forwards behind the pharynx; or it may extend behind, the sterno-mastoid muscle to the side of the neck ; or into the axilla, or the thorax ; from the dorsal or lumbar vertebrae, abscess may present directly backwards, or forwards into the thorax or abdomen ; or it may extend downwards—through the aortic opening in the diaphragm, in the case of dorsal abscess—and forwards, between the abdominal muscles, to some point in front of the abdomen; or to the external abdominal ring; or, guided, apparently, by the obturator vessels and nerve, to the obturator foramen, it points in the upper part of the thigh ; or, within the sheath of the psoas muscle to the upper part of the thigh, more externally, it appears as psoas abscess ;—or passing thence lower down, it may point in the popliteal space, the calf, or even as low down as the ankle; or extending, from its seat of origin, downwards, and inwards, into the pelvis; this abscess may point at the side of the vagina, rectum, or sacro-sciatic foramen; or escaping thence, burroAV externally between the bone and gluteal muscles, thus presenting in the gluteal region. Abscess by translation is further illustrated, by extension from the seat of origin in the shoulder joint to the elbow ; or from the hip to the knee. [P. p. 492.] The Signs of any such abscess are ; a fluid, fluctuating swelling, like that of an ordinary abscess; but its concomitant redness, heat, and pain, are absent. Some degree of inflammation may ensue, from the weight of pus on the most dependent part of the abscess, and pain also may be ex- perienced, owing to pressure on nerves in the neighbourhood. INFLAMMATION. 55 Hectic Fever.—The constitutional disturbance or hectic fever conse- quent on suppuration and abscess, is characteristic. Commencing at a variable period in the course of inflammation, the first symptoms are those of prostration with excitement. A sensation of chilliness or a shivering fit—rigors, announce the one, while the other—nervous excitement—is exhibited by restlessness and sleeplessness, the pulse also retaining its frequency, or rising in rapidity, although losing its force and hardness. The heat and flush of skin subside, a cold clammy sweat supervenes, the urine becomes pale, abundant, and deposits a pinkish sediment of lithates. The tongue loses its broAvn fur, is white and pasty with a bright scarlet tip; the appetite is very capricious, sometimes absent, with loathing of food and even vomiting; while profuse watery diarrhoea succeeds to the previous constipation. Progressive emaciation and trembling weakness bespeak' the failure of nutrition; and the general course of the symp- toms at length proclaims the victory of exhaustion. Hitherto inflammatory fever has subsided uninterruptedly ; but if the struggle be prolonged, it acquires an intermittent character,—exhaustion prevailing, yet with recurring efforts of excitement, particularly of the circulation, followed by increased secretions from the skin, kidneys, and bowels. Thus, towards evening, after a day of dread exhaustion and when the skin is pallid, a chill is felt; soon the pulse rises in force slightly, and in frequency to perhaps 100 or 130 beats per minute. Then the patient temporarily revives; the hollow cheeks are crowned with a tint of crimson hue, and the sunken eyes are lustrous; giving to youth and beauty a complexion and an expression which are not of this world. The palms of the hands and soles of the feet feel hot and dry. During the night or towards morning, this fitful fever abates with profuse per- spiration, urgent liquid diarrhoea, and probably diuresis. Daylight is welcomed, but only with feelings of greater prostration. Such is hectic fever. Intermittent, it recurs at various periods; frequently as a quotidian, sometimes as a tertian or quartan. Thus far resembling other intermittent fevers ; hectic has diagnostic dif- ferences. It seldom recurs, as Dr. Thomson observed, at a period per- fectly regular, for more than three or four paroxysms. Then recurring at irregular intervals, it may disappear entirely for ten or twelve days; unlike the course of ague. Moreover, the intermissions of hectic are not complete, the pulse still remaining above par, and very easily excited. It is rather a remittent fever. Hectic, therefore, may recur two or three times daily ; and a very slight degree of emaciation, a pulse a little quicker than ordinary, with a slight increase of heat, particularly after meals, are sufficient to constitute incipient hectic. These are the earliest symptoms. Rigor is not necessarily the earliest, nor the most constant constitutional announcement of suppuration, and of approaching hectic. This symptom may be present without suppuration and consequent hectic, as the harbinger of an ague fit, or as arising during inflammation from exposure to cold; or from the mere introduction of a bougie into the urethra. On the other hand, hectic fever sometimes supervenes stealthily, Avithout previous rigors. Pathology of Hectic.—The causative relation of suppuration to hectic fever, would appear to be, not through purulent infection of the system, but through absorption of the disorganized textures, and thence propor- tionate to the progress of suppuration. Purulent infection is irreconcilable with known facts. Pus often 56 GENERAL PATHOLOGY AND SURGERY, exists in the body Avithout hectic supervening—as, for example, in chronic diseases of the joints, and in psoas abscess. Probably, however, in such cases absorption is not very active. In other cases, pus is readily ab- sorbed, yet Avithout inducing hectic. A large bubo will sometimes sub- side in a few days without any symptoms of hectic, and every pus- secreting ulcer is liable to absorb its own secretion, and yet hectic is an unusual comcomitant. Purulent absorption, therefore, is not a cause of hectic fever. On the other hand, I am not prepared to assert that hectic ever occurs without suppuration. Assuredly the quantity of pus formed is no measure of the degree of hectic which shall ensue ; for after amputation, say, of a compound fracture, a much larger quantity of pus may form eventually, before convalescence, than had been secreted during the period prior to amputation, and yet the hectic shall subside. Recovery follows the removal of the disorganized part. In some way, therefore, a causative relation exists between the disorganization of a part, and the supervention of hectic. It cannot be that the progressive destruction of nerves by suppuration, and the injury thereby continuously inflicted on the nervous system, gives rise to hectic, for the symptoms are not those of nervous irritation, and, moreover, they are intermittent, or at least remittent. This certainly looks as if some noxious matter was gradually absorbed and accumulated in the blood, until thrown off by a hectic paroxysm, again to reaccumulate. The matter in question is not pus, or if absorbed it does not infect: by exclusion we are led to infer that the morbid matter is probably the debris of the disorganized textures. Clinical observations and examinations of the blood in hectic are Avanting to confirm this view ; meanwhile it is a significant fact, that the urine deposits lithates during the decline of each hectic paroxysm. This interpretation of hectic indicates the relationship existing between the progress of suppuration and itself. If hectic arises from absorption of disorganized textures; then, it must increase with the progressive formation of pus: not that pus, in such case, itself infects, but because its formation necessarily implies the concurrent and corresponding absorption of the encompassing textures, and by thus poisoning the blood, induces hectic fever. Suppuration and hectic are, therefore, related indirectly, as cause and effect; and more- over, the quantity of pus accumulating or discharged, actually becomes a fair measure of the degree of hectic. Certain acknowledged principles of preventive treatment admit of explanation by the theory I have advanced. Absorption of the textures is checked when the progressive accumulation of pus is prevented; hence, the importance of making an early, free, and dependent opening, for this equally alloAvs any debris of the tissues to escape. Again, absorption of dis- organized tissues is altogether prevented by removing them ; hence, the necessity for amputation where their destruction is extensive and beyond hope of recovery to a healthy condition. Amputation under these cir- cumstances is often followed by surprisingly beneficial results. As Hunter originally observed, a hectic pulse at one hundred and twenty has been known to sink to ninety in a few hours after removal of the hectic cause. Persons have been known to sleep soundly the first night after- wards who had not slept tolerably for several preceding weeks. Cold sweats have stopped immediately, as well as those called colliquative. Purging has immediately ceased, and the urine begun to drop its sedi- ment. INFLAMMATION. 57 All these facts and considerations harmonize with the theory, that hectic fever arises from absorption of disorganized tissues. Pus itself sometimes, apparently, enters the circulation, as pus; but this produces very different constitutional symptoms and results; those of pyemia, followed by secondary abscesses. The circumstances under which purulent infection arises will be noticed, more particularly, in connexion with that subject. Respecting the symptoms, it may be here summarily stated, that they are still those of a blood-poison, and of a typhoid character, but the exhaustion induced is more speedy, and more over- whelming—more typhoid; and the poison is either not eliminated at all, or insufficient to allow of marked intermissions,—the fever is less intermit- tent, or more continued, than hectic. (3.) Destruction of texture, as a result of inflammation, comprises mortification and ulceration. Mortification, or the death of a part, re- ceives different names according to the partial and recoverable, or total and irrecoverable, loss of vitality in the part affected; the one condition being named gangrene, the other sphacelus. Both these terms refer to death of the soft textures, and when this takes place to a limited extent and is accompanied with ulcerative separation from the living textures, it is termed slough, and the process, a sloughing of the part; when bone is affected, mortification is called necrosis, and the dead portion, a seques- trum, and its separation, exfoliation. This latter term is sometimes restricted to the detachment of an external portion of bone, in the shape of a thin scale or plate. Ulceration may be conveniently described first, as being in its nature introductory to mortification. The phenomena of ulceration generally, are these:—A portion of integument having become inflamed, from any cause; after a few days a small piece separates and comes away, leaving a corresponding loss of substance—a chasm, from which a discharge, variable in kind and quantity, issues. Thus, then, the skin, or mucous membrane, with perhaps the subjacent cellular tissue, has undergone a " solution of continuity," slowly, however, as contrasted with a Avound, or other recent breach of texture, and an ulcer is formed. Its formation and extension constitute ulceration. The pathological nature of this process has long been a disputed question. All the explanations advanced may be reduced to two heads. Firstly.—That ulceration signifies molecular disintegration, liquefac- tion, and separation of the soft parts, thereby leaving a chasm. Secondly.—That ulceration is an illustration of the process of absorp- tion, the lymphatics and veins being jointly engaged, more especially the former. Possibly, both modes of removing the disorganized textures co-operate in ulceration. [P. p. 512.] Textures undergo certain changes of structure preparatory to their ulceration. The latter is essentially molecular disintegration ; but, in so far as it proceeds from inflammation, degeneration of texture prepares the way for such disintegration. And the previous degeneration is generally fatty. The proper discharge from an ulcer—the product of ulceration, not of a granulating sore—is ichor. It is a thin sanious fluid, colourless or slightly yellow, structureless, but mixed with exudation, pus, and blood, cor- puscles, and A\rith the debris of the ulcerating textures. Hence its variable appearance. Its essential chemical composition is unknown. Ichor cor- 58 GENERAL PATHOLOGY AND SURGERY. rodes the living tissues, and is thus distinguished from pus, which it often resembles in appearance. Thus also it maintains and extends ulceration. Ulceration, although itself a destructive process, is sometimes restora- tive or reparative, in virtue of its purpose. For example, by the pointing of an abscess and the natural formation of an opening for the escape of matter externally, or internally into some channel through which it can be safely discharged,—as through the bronchi, stomach, intestine, or bladder. Mortification is only another mode in which any part of the body may die; a reciprocal relation subsisting between this process of destruc- tion and ulceration. They differ in degree, but are one in kind. Ulcera- tion may be exaggerated into mortification, and this may subside into that. Both are convertible by different gradations of the same process of destruction. Thus, noAv and then during ulceration, some temporary cause may accelerate the inflammation ; a larger portion of tissue under- goes degeneration and dies, than can, conveniently, disappear as dis- charge, and a corresponding portion, therefore, of dead tissue becomes visible in the shape of slough; instead of having been removed imper- ceptibly by molecular disintegration and liquefaction, aided by the corro- sive action of the ichorous secretion. Accordingly the ulcer presents a rim of slough, and from time to time, another and another, as the margin of the ulcer recedes and enlarges, either by sloughing or ulceration. Of course the sloughs will vary in their depth and extent, sometimes ap- proaching the result of molecular disintegration, sometimes appearing as obviously portions of dead tissue, plainly showing the transition of ulceration to mortification. Small fragments of bone may be detached and cast off with the fluid from an ulcerating surface, and these, observes Mr. Paget, when they are not fragments of tissue detached by ulceration extending around them, are good examples of the transition that may be traced from ulceration to sloughing or gangrene of parts. The conditions which constitute inflammation, if operating with suf- ficient duration, end either in ulceration or mortification. And indeed the very fact of pus—a product of inflammation—accumulating in any texture or organ, by progressive suppuration, necessarily implies the death and removal of the occupied portion. The determination and kind of blood, the kind of texture, and the nervous influence on the part, are the conditions referred to ; but each or all of them are so modified as to have a tendency to death. The determination of blood may be more intense, or the kind of blood may be that which indicates the operation of some blood-poison, or at least a morbid condition of the blood, as in car- buncle and boil, phlegmonous erysipelas, sloughing bubo, and certain secondary syphilitic ulcerations, hospital gangrene, malignant pustule, malignant scarlatina, and small-pox. Unyielding textures are liable to gangrenous inflammation, owing apparently to strangulation of the capil- lary vessels, consequent on effusion which cannot be accommodated inter- stitially. Inflammation of any texture situated beneath one of this kind, as beneath a fascia or tendinous aponeurosis, has also a gangrenous ten- dency, and thus subpericranial inflammation is soon followed by gangrene and sloughing, exposing the scalp. But inflammation of a loose texture, if a comparatively avascular one, as the subcutaneous cellular tissue, is prone to sloughing, owing apparently to strangulation of the vessels, consequent on the ready accumulation of effusion—e.g., in phlegmonous erysipelas. The influence of the nervous system is shown by the ten- INFLAMMATION. 59 dency to sloughing from injury to the spine. Mortification of the ankle has thence followed within twenty-four hours. (Brodie.) Ulceration of a part may supervene on injury of the nerves leading thereto; a central penetrating ulcer of the cornea was thus formed in consequence of destruction of the trunk of the trigeminal nerve by the pressure of a tumour near the pons varolii. (Paget.) And in another case, under my own observation, in the Royal Free Hospital, a similar ulcer of the left cornea followed an injury to the posterior part of the left side of the head. There was also considerable injection of the conjunctival vessels, and mucous secretions. These symptoms ceased, and the ulcer healed subse- quently, leaving a slight opacity in the centre of the cornea. Other illustrative cases are on record. [P. p. 566.] The Signs of gangrenous inflammation are,—acute burning pain, instead of the throbbing of approaching suppuration. The redness deepens into purple, and thence to a livid hue, a change of colour due to stagnation of the blood in the dying part. The swelling, moreover, is peculiar, for here the textures are disintegrating and softening, macerated also by the effused fluid in which they are soaked. Hence a flabby soft- ness is presented. Phlegmonous erysipelas, as it advances, well illustrates these signs of gangrenous inflammation. Their diagnostic value is assured by their constancy and exclusive- ness ; they are never absent collectively in gangrene resulting from inflammation, nor present collectively in any other disease. Acute burn- ing pain is, perhaps, the earliest or premonitory symptom. From this condition of local disorganization the constitutional disorder at once commences. More insidious, its symptoms resemble those of pyaemia, although differing in degree. A wild, apprehensive look, with great restlessness, are conspicuous; the features and manner at length become more composed, and the face assumes a pallid hue. The skin over the whole body and the tunicae conjunctivae sometimes acquire a peculiar yellow colour. (Brodie.) Utter prostration of mind and of muscular power gradually supervenes, and a quivering subsultus tendi- num. The pulse beats very feebly, rapidly, and irregularly, feeling like a rough wire drawn under the finger. The secretions are soon per- verted; the skin, at first hot and dry, is now bathed with a cold, clammy sweat; the urine, fetid and scanty, may be suppressed; a brown, rough, dry tongue is accompanied with nausea and a putrid diarrhoea. As the powers of organic and of animal life fail, involuntary excito-motions predominate; spasms and convulsions shake the mori- bund body, while coma ends in death. This represents the course of an extreme case of gangrenous inflam- mation ; but, short of it, various degrees of the same constitutional disturbance occur in different cases, and it represents also the constitu- tional disturbance which proceeds from spreading gangrene. But the gangrene may cease to spread. The reddish-brown tint of the skin in advance of the dead part becomes brighter and more circum- scribed. Shortly, a Avhite raised line of demarcation is seen in the living skin immediately adjoining the dead portion. Soon this line melts away into a groove by ulceration ; extending deeper, it forms a fissure, and suc- cessively passing down through tissue after tissue at length converges, and completely detaches the whole of the dead part. While the living organism is thus separating itself from the slough, adhesive inflamma- tion precedes the line or fissure of ulceration, and, corresponding to it in 60 GENERAL PATHOLOGY AND SURGERY. length and depth, simultaneously seals the blood-vessels; so as to effectually exclude any further communication Avith the dead tissues, and prevent absorption of their debris. The typhoid type of fever passes off, and is exchanged for some degree of inflammatory fever, which accompanies the process of separation and detachment of slough. The typhoid fever of gangrenous inflammation arises, apparently, like hectic fever, from absorption of the disintegrating and dying or dead textures. This conclusion rests on two species of evidence. Firstly, the fever arises, and invariably, when mortification has advanced to sphacelus,—i.e., when dead tissues are present; and, more- over, when the veins, in some cases at least, are free to absorb. Secondly, it begins to subside, and invariably, when sphacelus has ceased to spread,—i.e., when the living organism is separating itself from the dead part, and when adhesive inflammation of the blood-vessels, cor- responding to the line or fissure of separation, has intercepted any further communication through these vessels with the dead tissues. [P. p. 526.] t Mortification, itself a destructive process, is, like ulceration, occasionally restorative, or reparative, by virtue of its purpose. It is so in the loosening and evulsion of a foreign body by sloughing of the part wherein it is imbedded,—the natural process whereby a thorn in the flesh is extricated. The spontaneous cure of aneurism, by sloughing, is another example; with many others of similar character. [P. p. 803.] Treatment of Inflammation, and its Consequences.—The earliest occasion for interference with inflammation is determined by considering its purpose with reference to the part affected. If it be reparation of some loss of structure, or the construction of some new and useful mechanism, in connexion with such part; the process should be allowed to run its course, or Avhen inadequate, it should be encouraged by main- taining or superinducing the requisite conditions. . Reparatively, inflammation is available in the healing of incised wounds or fractures, Avhen the soft tissues or the bone are indisposed to unite by non-inflammatory adhesion. Other instances of this kind are cited at p. 44, and many additional illustrations will occur in practice. Constructively, the plastic operation of lymph-deposit is available for the opening of an abscess safely from a great depth and by a dangerous route; and here also many analogous cases, additional to those noticed at p. 45, are sure to come under the observation of the watchful clinical observer. Supplemental to the restorative purpose of inflammation, as viewed productively, the destructive aspect of this process may have a similar character. Thus, ulceration forms an opening for the discharge of super- fluous organizable material,—pus; and mortification, by sloughing, is useful in loosening and facilitating the evulsion of a foreign body. Obviously in any such case, if interference be necessary, the destruction of textures can be turned to good surgical account. Whenever the purpose of inflammation is neither reparative, con- structive, nor usefully destructive, the process should forthwith be arrested, or subsequently conducted to a favourable issue. In accordance with the pathology and causes of inflammation, the following are the general indications of treatment to be observed : (1) The removal of any exciting cause or causes in operation is the INFLAMMATION. 61 fundamental rule of treatment; bearing more especially on the arrest of inflammation The causes alluded to comprise the various kinds of irri- tant matters—mechanical, chemical, and vital—that were enumerated among the " external" causes of inflammation (p. 39); moreover, any constituent of the organism which has become a foreign body, and morbid products, which are more apt to assume that character. They are the " internal " exciting causes of inflammation (p. 39). The signifi- cance of their operation, and the efficacy of their removal, as causes of irritation, are well illustrated in the every-day practice of Surgery. Blood, extravasated and decomposing, is a poison; its evacuation is followed by the subsidence of inflammation and constitutional distur- bance. A slough of soft textures contaminates; its withdrawal is similarly beneficial. The extraction of a piece of dead bone will arrest a discharge of pus which had continued for weeks, months, or years, and had re- duced the patient to the brink of the grave. Excretions are obnoxious when decomposed, and powerfully irritant to parts not intended by nature for their reception ;—as urine extravasated into the cellular tex- ture of the scrotum. And the evacuation of excretions under these circumstances arrests the concurrent inflammation. Hence the efficacy of free incisions in the scrotum in the case supposed. Of morbid products, a calculus in the kidney, provokes nephritis; this inflammation ceases when the stone passes down the ureter into the bladder, and is succeeded by cystitis, which in its turn subsides when the foreign body is removed by lithotomy or lithotrity. These examples will suffice to enforce the general rule of treatment. Whenever the exciting cause in operation—whether externally or internally—is removable, the process of inflammation not unfrequently ceases with its removal. Fortunately also the fulfilment of this indication meets the requirements of an already large class of cases, and an increas- ing class as our knowledge and detection of causes becomes yet more early and exact. It is thus that inflammation of local origin may often be arrested, as compared with that which depends on constitutional causes. In all other cases the process continues and runs its course to struc- tural results if unopposed. The treatment required is no longer preventive only, but counteractive also. (2) Removal, therefore, of (a) the pathological conditions or elements which, co-operating, constitute inflammation; and of (b) its local con- sequences with their concomitant constitutional disorders. (a) The conditions to be overruled by appropriate remedial measures comprise: accelerated textural productiveness, and consequent ac- celerated textural waste or destruction of texture; the accompanying determination of arterial blood, and any morbid condition of quality in the blood supplied to the inflamed texture or organ; and perversions of the nervous influence. Experience has established the remedial efficacy of certain measures, both local and constitutional, and which constitute the " antiphlogistic " treatment. This term having been long since recognised in practice, it may be conveniently retained without implying any theory as to the modus operandi of the agents employed. Local antiphlogistic measures consist in the application of cold, heat, or warmth, with moisture, as in the common bread-and-water poultice or moist spongio-piline epithem ; in blood-letting by leeches or scarification, 62 GENERAL PATHOLOGY AND SURGERY. an elevated posture of the part inflamed; incisions, sufficient to relieve tension; blisters, setons, caustics,—as caustic-potash, mineral acids, iodine, burning heat or the actual cautery, and other strong irritants; pressure. Constitutional or systemic measures include—blood-letting by venesec- tion, purgatives, diaphoretics, diuretics, starvation and the antiphlo- gistic regime, antimony, opium, mercury, wine, brandy, ammonia, and other stimulants; cinchona bark, the mineral acids, and other tonics; cod-liver oil, nutritious diet. Taking this list of remedial agents, some are of the most opposite character, but they may all be used appropriately, in the course of in- flammation generally, in the order enumerated. Local Appliances.—Cold is more efficacious in the early treatment of inflammation, and as affecting external parts of the body. It may be applied, according to the degree of cold required, by means of ice, or by an evaporating lotion of spirits of wine and water in various proportions. Lead lotion—the liquor plumbi diacetatis, a drachm or more to eight ounces of water—is another refrigerant, but far less serviceable. The application of cold externally will even reach an internal organ, as the brain in meningitis, through the interposed scalp and cranium ; but in all such cases the more intense cold of pounded ice in a bladder is neces- sary to produce a beneficial effect. To some internal organs cold can be applied directly, as to the stomach in gastritis, by swallowing bits of ice. The leading fact to be observed in every case is, that refrigeration should be continuous and uniform. This two-fold requirement is best fulfilled by some form of self-acting irrigator. A skein of cotton pen- dant from a bottle of cold water suspended over the part will supply a constant dribbling stream, and thus answer the purpose very well. Its efficiency is witnessed in preventing or arresting inflammation of the large joints. The best rule for the application of cold is to employ it in those cases where, and so long as, the sensation is agreeable to the patient; otherwise to discontinue it. Heat, moderate, with moisture, is preferable in those cases where cold is uncomfortable to the part, or occasions any shivering sensation. Moist warmth is more advantageous also when inflammation is established, the remedial efficacy of cold being restricted rather to incipient inflam- mation. Warmth and moisture are conveniently applied in the shape of a light, soft bread-and-water or linseed meal-poultice ; or by means of spongio-piline soaked in warm water. The latter surpasses any kind of poultice, which is apt to dry, thus becoming an irritant, and is uncleanly. Spongio-piline is even more retentive of moisture than an equal sub- stance of flannel, and more suitable, therefore, as an epithem. Blood-letting locally is advantageous whenever it appears desirable to make a sudden, considerable, and direct impression on an inflamed part, as the eye in iritis. Leeches, scarification, or cupping are available for this purpose. Leeches can be applied to a part which is inaccessible to the cupping-glass, as the os uteri. But the drawing action of a cupping- glass, the pressure of the atmosphere being removed, penetrates to a greater depth than the abstraction of blood by leeches. Hence cupping is more suitable for inflammation of internal organs, as the kidneys when inflamed. In employing either mode of topical blood-letting, it should be re- membered that haemorrhage may continue for some time after a leech-bite or cupping. An average-sized leech, when fully distended and ready to INFLAMMATION. 63 drop off, holds about a drachm and a half of blood, and the amount drawn by a cupping-glass can be watched and measured ; but the quantity which flows subsequently should always be taken into account and alloAved for, more especially with regard to leeches, the after-haemorrhage from which is more uncertain—by fomentation amounting to half an ounce, or far more, even spontaneously. A single leech has thus proved fatal to an infant. The haemorrhage is, perhaps, best arrested by touching the little triangular punctured wound firmly with nitrate of silver. Dry cupping, or the application of an exhausted cupping-glass without previously using the scarificator, is a method of drawing blood to the surface, without abstracting it from the mass in circulation; yet it may be questionable whether the blood thereby rendered stagnant, is not spoilt for the purpose of any returning circulation. The corpuscles are damaged or destroyed, and this change will, of course, be more likely to occur, the more frequently the cupping-glass is re-applied to the same part; so that the blood might as well be withdrawn from the body, as left partially extravasated with its corpuscles broken up. Position.—An elevated posture of an inflamed part is equivalent to the local abstraction of blood. The determination of blood becomes diminished, and the return of blood facilitated; whereby the quantity in the part is greatly reduced. Elevation of posture has, therefore, the same effect as local abstraction of blood, or will, at least, further aid its effect; and this resource is a good substitute for, or a useful adjunct to, local blood-letting. Its efficacy is witnessed in the treatment of inflam- mation affecting different parts of the lower extremity; as in compound fracture of the leg, dislocation or disease of the knee-joint, and other morbid conditions. Incisions are appropriate to relieve tension; this being caused partly by distension of the blood-vessels in the part inflamed, but principally by the serum effused. Here, then, as with regard to local blood-letting, the guidance of pathology, in the treatment of inflammation, is somewhat avail- able. For the incisions should be made in extent and depth according as either condition of tension predominates. In chemosis, the sub-conjunctival collection of serum suggests the kind of incision necessary. In glossitis, vascular distension is relieved by scarification over the upper surface of the tongue, rather than by one free incision. In phlegmonous erysipelas, both sources of tension are relieved by incisions in different parts of the skin, as the chief seat of vascular distension, and extending down to the subcellular texture, which is engorged with serum. In all cases, how- ever, the requisite length and depth of incisions must be determined practically, by their effect in relieving tension. Incisions for the discharge of pus and slough Avill be considered in a subsequent part of the treatment of inflammation. Irritants.—Blisters, setons, caustics, as potass-fusa, the mineral acids, iodine, burning heat or the actual cautery, and other strong irritants, are remedial measures of much value in the more chronic forms of inflammation. Their intensity of action varies, but their kind of action is said to be counter-irritant or derivative from the inflamed part, by exciting inflammation in the neighbourhood of that part. This may be true in some cases. In other cases irritants have the opposite effect, they increase the inflammation in the part itself; either bringing it to a termination by resolution, or by promoting effusion and hurrying on the process to suppuration. 64 GENERAL PATHOLOGY AND SURGERY. According to the object in view, therefore, we should apply any such agent more or less nearly in relation to the part inflamed, and be guided in our choice of one or other by regard to the intensity of its operation. A seton consists of a skein of silk, worsted, cotton, or hemp thread ; which is attached to the eye of a needle, three or four inches long, and a quarter of an inch in breadth. (Fig. 5.) The integument is pinched up between the thumb and fore-finger, and the needle passed through, carrying the seton-skein after it; the needle is then cut off, leaving .the lash of threads in the subcutaneous track, and either end hanging out. Fig. '5. Inflammation is soon excited, with suppuration; and this counter- irritation and derivative discharge are established for so long a period as it may be desirable to allow the foreign body to remain. If the needle be not at hand, the seton may be passed by means of a common probe ; a bistoury having been passed through the fold of integument, the armed probe is slid along the flat of the blade. A few examples will illustrate the remedial value of this class of agents in inflammation, subject to these two regulations. Blistering the skin is very serviceable in chronic and deep-seated inflammation of the bones and joints. In chronic arthritis, the bulky ends of bone which form the knee-joint and their articular cartilages, are most advan- tageously influenced by the action of blisters, placed above or below the joint. A seton or issue, which produces a constant discharge of pus from the neighbourhood of the vertebrae, is often of signal service in caries of the bodies of these bones. When applied to the nape of the neck, the same beneficial effect is witnessed in chronic meningeal inflam- mation of the brain. Of caustics, the potass-fusa is sometimes useful in similar cases, but it is comparatively seldom employed. I rarely use this kind of caustic, and indeed, it seems to be going out of fashion. Nitrate of silver, lunar caustic, promotes the resolution of a whitloe, a bunion, a hordeum or stye in the margin of the eyelids ; and such like intractable conditions of inflammation. Of the mineral acids, as caustic appliances, nitric acid, undiluted, is of great service for converting phagedaenic ulceration into inflammation with healing granulations; but this is scarcely an appropriate illustration as to the treatment of inflammation itself. Iodine " paint," consisting of equal parts of iodine, and of iodide of potassium, to two parts of rectified spirit, and four parts of water, is a strong irritant, of considerable value in removing the effusion and indura- INFLAMMATION. 65 tion attending chronic inflammation generally. Various stimulating embro- cations, as camphor and ammonia, with olive oil, are thus used. The actual cautery may be resorted to, Avith marked benefit, occasionally, in cases of deep-seated and chronic inflammation affecting the joints and bones, and especially the vertebrae. Thus also the burning-moxa Avas formerly in some repute. Placed over the spine, and alloAved to burn doAvn, it produces a circular slough of skin about the size of a shilling or half- crown. Several moxae were sometimes applied in a row, simultaneously. But the remedial efficacy of such a powerful counter-irritant measure as even one moxa, is very doubtful; Avhile the severe and continued pain is a decided disadvantage, and more so in virtue of its tendency to aggra- vate inflammatory fever. This consideration, indeed, restricts the use of the more poAverful kinds of counter-irritants. Unlike the pain caused by the clean cut of a knife in most surgical operations, the pain induced by strong cauteriza- tion is felt when the influence of the chloroform has ceased, although the part itself may be killed outright. " It deserves full trial," observes Mr. Simon,* '' whether every intense, and consequently painful form of counter-irritation, might not be superseded by the employment of other means, less intense, but more extensively applied ; whether, for instance, ten inches of poultice, may not be equivalent to four inches of blister, or to one inch of issue." In respect to thoracic inflammation, for example, where blistering is employed as a matter of routine practice, the unsurpassed clinical authority of Professor Skoda pronounces such treatment to be always useless, sometimes hurtful. Re-investigation, therefore, is more especially needed here ; further experience, guided, if possible, by the light of pathology. Constitutional Remedial Measures.—Systemic blood-letting, by vene- section. This mode of depletion has fallen nearly into disuse, in the treat- ment of inflammation. The explanation of this change of practice on the part of the Pro- fession generally, is referable to two entirely different views, each having its partisans. According to one school, so to speak, the human constitu- tion has itself undergone a great change in the loss of vital power, whereby febrile symptoms have altered from an inflammatory to a typhoid character. The late Dr. Alison-)- was the champion of this doctrine. On the other hand, it is contended, that the principle on which blood- letting had hitherto been practised is opposed to Pathology; and that our more advanced knowledge of this science has led to its abandonment. This explanation is offered and ably advocated by Dr. J. H. Bennett.+. Assuredly the change of practice has taken place, and experience sanctions its propriety. As to its interpretation ; probably in regard to this, as to many vexed questions, both parties are partly right, and partly Avrong. But it is not only in the present as compared with former practice, in one period as compared with another, that differences of opinion have prevailed respecting the remedial value of general bleeding in inflamma- tion • it is no less remarkable—as Mr. Simon observes—that contem poraries living under the same sky, and practising in the same year on the same disease, have waged controversy on this subject; and not unfrequently it has seemed probable that medical juries, inquesting any * Op. cit., p. 103. t Edin. Med. Journ., 1856, March. X Principles and Practice of Medicine. 66 GENERAL PATHOLOGY AND SURGERY. given dead patient, would divide in equal numbers, whether much bleeding or little bleeding had killed the man. In explanation of this anomaly the same author urges; that, prac- tically, all impartial observers seem now to agree, that Avhile there are inflammations Avhich bleeding can relieve, yet there are also inflammations Avhich every act of depletion, instead of diminishing, will increase. And the obvious inference from this fact is one which, certainly, the pathology of inflammation would indicate; that the therapeutical value of blood- letting does not so much consist in its directly controlling inflammatory excitement, as in its controlling some condition, which may or may not be concomitant. What then is this condition ? Reserving for a moment that which Mr. Simon suggests, I would first notice another. Forcible contractile action of the heart, with a strong pulse, un- doubtedly maintains the local determination of blood; although this latter may be aided by the accelerated nutritive changes of the part itself, using up the plasma supplied, and thereby continuously eliciting exudation from the capillary vessels. General blood-letting, by venesection, powerfully relieves the action of the heart, even to syncope. But. with inflammatory fever, the system is more tolerant of loss of blood than in health, or other diseases. This increased tolerance was first clearly shown by Dr. Marshall Hall, the results of Avhose nrvestigations are given in the folloAving table, which represents as compared with health, the mean quantity lost before incipient syncope is induced, the patient being in the sitting or the erect posture :— 1. Healthy Tolerance : This depends on the age, sex, strength, &c, and on the degree of thickness of the parietes of the heart; but it is about . . . . • § xv. 2. Increased Tolerance: Congestion of the brain .....§ xl—1. Inflammation of serous membranes . . . \ Inflammation of synovial membranes . . . > g xxx—xl. Inflammation of fibrous membranes . . . j Inflammation of the parenchyma of organs— brain, lung, liver, mamma, &c.. . • • 3 xxx. Inflammation of skin and mucous-membranes, erysipelas, bronchitis, dysentery . . . § xvi. 3. Diminished Tolerance: Fevers—eruptive and others. . . . . § xi—xiv. Delirium tremens, and puerperal delirium . . § x—xii. Laceration or concussion of the brain . . .") Accidents, before the establishment of inflammation > g viii—x. Intestinal irritation . . . . . .1 Dyspepsia, chlorosis ......§ viii. Cholera . . . . . . . . § vi. The condition to which Mr. Simon refers as deserving especial notice, is that state of the vascular system, which, often designated "vascular tension," is characterized by a hard pulse. Both these conditions—forcible action of the heart and vascular tension—are alike diminished by general bleeding; the pulse becoming weaker, slower, perhaps more regular, and softer. The propriety of having recourse to this reducing measure should INFLAMMATION. 67 therefore be determined and regulated by reference to the state of the general circulation, as indicated by the characters of the pulse in respect to its force and hardness. But the necessity for blood-letting is propor- tionate also to the physiological importance of the organ affected, which might otherwise be permanently damaged by the structural results of inflammation ; and the urgency on this ground will be indicated by the functional disturbance which the organ itself suffers and induces by its functional relation to other organs. These conditions of organic signifi- cance are not accompanied with a corresponding tolerance of blood-letting. For example, they co-exist in pneumonia, especially double pneumonia; the lungs being highly important organs functionally, dyspnoea and general functional disturbance thence arises. Yet in this disease the tolerance of blood-letting is thirty ounces, as shown by the table, or only double that of health, and less by twenty ounces than that of the highest range in the list. The effects of blood-letting are more than momentary. This should always be remembered in considering the necessity for producing a poAverful and persistent impression on the general circulation. Such im- pression can be made in either of two ways; the one or the other having a salutary tendency, according to the previous duration of the inflammation. Recent inflammation may be arrested by the loss of a moderate quan- tity of blood, suddenly—i.e., through a large orifice or from both arms simultaneously, and the patient being placed in the sitting posture, so as to induce syncope. Inflammation of a few days' duration will be more surely brought to a termination by the loss of a larger quantity of blood, gradually; the bandage above the orifice in the vein being loosened, and the patient in the recumbent position, to avert the tendency to syncope. Or venesection may be repeated from time to time, according to the symptoms ; thereby renewing and further maintaining the impression originally made on the circulation. The advantage of gradual over sudden loss of blood, in inflammation of some duration, is evinced by the fact, that if the first impression be thus maintained, it is found unnecessary to repeat it. Local blood-letting will prove sufficient subsequently, in most cases; and advantageously so, by directly affecting the inflamed part without powerfully and persistently influencing the system. And it should never be forgotten, that the permanency of systemic impression is directly pro- portionate to the quantity of blood lost. Nutrition is reduced throughout the body, and any process of reparation may fail. Probably the vital injury of excessive blood-letting or of such haemorrhage accidentally, is never quite recovered from. Purgatives not only remove faeculent matter, which would otherwise be a source of irritation affecting also a large extent of intestinal mucous membrane; but, their operation is depletory by inducing the discharge of serum from the blood. Purgatives are, therefore, a useful adjunct to, or even a substitute for, general blood-letting, in relieving vascular ten- sion. Different kinds of purgatives appear to act on different portions of the intestinal tract; and hence a combination of these medicines may prove more efficient than any one alone. Salts and senna, jalap and rhubarb, are familiar examples of such combinations. It would be very desirable to acquire more extensive and exact knowledge respecting' the action of purgatives for this purpose. 68 GENERAL PATHOLOGY AND SURGERY. But they probably have also different selective powers,.in promoting the discharge of different constituents of the blood, and various effete or noxious matters; thus affecting the quality as well as reducing the quantity of the blood in circulation. Here, more especially, further clinical observation would be highly desirable. Besides removing irritant matter, and having a depletory and an excretory operation, purgatives are said to have a derivative action, apparently by inducing hyperaemia of the intestinal mucous membrane. In this way they are supposed to antagonize inflammation of the brain, for example. But it is a kind of action which prohibits the continued use of purgatives, lest intestinal inflammation be superinduced. The purgative operation of mercury is referable to its agency in pro- moting the secretion of bile,—itself a natural purgative. Besides, how- ever, having this effect, the " cholagogue" action produced by larger doses of mercury is equivalent to general blood-letting as a depletory, and superior as an excretory, remedy; for the copious spinach-like evacua- tions produced are equally effectual in reducing vascular tension, and are specially excrementitious, without unnecessarily diminishing the quantity of blood in circulation. Calomel, in doses of five, ten, or twenty grains, and repeated as occasion may require, is perhaps the best cholagogue. The action of mercury on the liver as a secreting and excreting organ, suggests a general inquiry respecting the action of other purgatives, specially on the glandular apparatus of, or associated with, the gastro- intestinal organs. What medicines specially affect the secretion of the pancreas; what, with regard to the glands of the gastro-intestinal mucous membrane; namely, the tubular, the cardiac, and the lenticular glands of the stomach; the glands of Brunner, the crypts of Lieberkuehn, and Peyer's glands, of the small intestine ; and the innumerable follicles of the large intestine ? Diaphoretics and diuretics—medicinal agents which increase or alter the secretions of the skin and kidneys, respectively—are purgatives in their way. They are depletory, excretory, and derivative. Such is the acetate of potash, a diaphoretic, and the nitrate of potash, a diuretic. Little or nothing is known of these, and similar medicines, in their in- timate relation to inflammatory fever. Experience alone sanctions their use. Their administration constitutes what is more particularly desig- nated " febrifuge" treatment. A liberal allowance of water, soda-water, or other bland fluid, seems to favour the excretory operation of these medicines; probably by diluting, and, as it were, washing away effete matters from the system. Starvation is another kind of depletion, by withholding the supply of nourishment. And if this were all that the term suggests physiologically, its significance therapeutically in relation to pathology, would be very simple. But starvation has reference to many differently constituted textures; each undergoing its own nutritive changes, and having its own food requirements. Consequently, the starvation of any one kind of texture, and kindred textures, is physiologically possible without, at least proportionately, depriving others of their food. Thus, the albuminoid textures, of which muscle is the type, might be starved, apart from the gelatinous, as skin and mucous membrane; and these again apart from osseous texture. The various artificial preparations of food have not, how'ever, hitherto reached this desideratum of composition, for the pur- poses of therapeutic treatment, yet it Avould bear very directly on inflam- INFLAMMATION. 69 mation,—accelerated nutrition,—as affecting different organs and their component textures. The " antiphlogistic regimen 'l is rather a negative than a positive regimen. Dietetically, it consists in abstinence from animal food and stimulating drinks, and in the moderate use of bland fluids, as barley-water, gruel, arrow-root. But it also implies the exclusion of all surrounding circumstances of excitement to mind or body. A cool and well-ventilated apartment, an easy bed, exclusion of light and noise, the prohibition of conversation, of the constant presence and attention of friends, and the banishment if possible of care; such are the principal features of this regimen. Antimony, as an internal remedy, most nearly resembles general blood- letting. After a dose of say, half a grain, repeated or increased to one or even two grains, every three hours, until vomiting occurs; the' effect on the circulation and secretions are very marked. At first, the pulse becoming more rapid and feeble, it dwindles down to a fine thread. Then, vomiting having occurred, the pulse loses its frequency, and perhaps regains its force, but acquires a peculiarly full and soft character; showing that vascular tension is overcome or relieved. Simultaneously, perspiration and the secretion of urine are notably increased ; and liquid evacuations from the bowels not unfrequently accompany this relaxation. The muscles also are flaccid and powerless. In short, the whole muscular system, voluntary and vascular, is relaxed; and a flux or flow takes place from various secreting organs, which further reduces the vascular ten- sion. Any local inflammation is thus materially diminished. A full dose of tartarized antimony Jiaving this result; similar effects, though in a less marked degree, and without the distress of vomiting, may be produced by smaller doses. Fortunately, however, vomiting soon ceases, while the beneficial influence continues with the full administration of the medicine; or this symptom may be controlled by administering it in the form of a saline draught Avith four or five minims of diluted hydrocyanic acid. The action of this remedy is most salutary when even nausea is not induced. Antimony will be most advantageously prescribed after general blood- letting to maintain its effects, and in proportion as the vascular tension, indicated by hardness of the pulse, continues. But either resource may be considered a substitute for the other; and experience gives the preference to antimony, generally. It is found to be most effectual in pneumonia, orchitis, and inflammation of other unyielding textures; less so with regard to serous membranes; and it is contra-indicated in enteritis. Opium is of signal service in the treatment of inflammation. It seems to act partly like antimony and blood-letting by overcoming vascular tension, but opium has the advantage of also subduing nervous excite- ment. Its administration is, therefore, most appropriate when this is the predominant element in inflammatory fever; or when excitement of the circulation declining, that of the nervous system with general weakness become prominent. It is thus that opium proves so beneficial after severe injuries or surgical operations; Avhere shock is followed by ex- cessive reaction, or prostration with excitement prevails over or outlasts inflammatory fever. In some cases, opium acts specially on the part injured or operated on, as by paralysing the peristaltic movements of the intestine after the operation for strangulated hernia. It seems also to influence, in some 70 GENERAL PATHOLOGY AND SURGERY. way, favourably, inflammation having an ulcerative or gangrenous tendency. The chief disadvantages attending the use of opium are ; the sickness it is apt to occasion at first, and constipation by its more continued use. The latter can be controlled or prevented by our next remedial measure, prescribed in combination with the opium. Mercury counteracts the constipating tendency of opium, and this, in its turn, overrules the aperient action of mercury; either medicine check- ing the intestinal influence of the other. The combination generally employed is calomel and opium; in the proportion of from one grain to five of the former, with a quarter of a grain to one grain of the latter, given as a pill every four hours or so. But does the continued administration of this familiar formula pro- duce any remedial effect, through the systemic influence of mercury ? This is debateable ground. Unquestionably, mercury can be intro- duced into the system—meaning thereby the blood in circulation—and it then produces peculiar symptoms; the gums becoming red, spongy, and tender, the breath having a peculiar foetor, and a metallic taste being experienced like that of copper in the mouth. The salivary glands under the tongue and at the angle of the jaw become somewhat swollen and painful, and the secretion of saliva increased. This associated group of symptoms, constituting " salivation " or ptyalism, announces that the system is under the influence of mercury. Mercurial infection, or " mer- curialism," as it is called, is in fact attested by the supervention of certain symptoms; just as the introduction of the syphilitic virus, for example, is followed, in the course of time, by enlargement and ulcera- tion of the tonsils, some definite skin eruption, and perhaps iritis; symptoms declaring the syphilitic infection to have taken place. So far then there are certain effects, specially due to the systemic influence of mercury. Formerly, also, and until recently, it was unanimously held, that the same influence prevented or retarded the effusion of fibrin, and pro- moted its absorption. That, " the constitutional action of mercury opposes the organizing efforts of inflammation," is the somewhat equiva- lent expression of Mr. Simon. Does this represent the remedial virtue of mercury in the systemic or constitutional treatment of inflammation ? A good illustration of such influence was supposed to be, the visible disappearance of lymph in iritis, apparently under the operation of mercurialism. Long as this therapeutic theory prevailed, and practice accordingly; there are reasons for doubting the accuracy of the one, and the efficacy of the other. That mercury exercises some kind of influence over nutrition, there can be no doubt; but it is questionable how far the natural course of inflammation, having induced the effusion of fibrin, may itself tend to absorption, apart from the co-operation of mercury. Mr. Simon limits the agency of mercury by the following qualifications; that, "if mercurial cachexia in its lesser degrees, and independently of the purging Avhich may attend it, has a real effect on inflammatory products, this effect probably relates only to such products as are not organized, and perhaps is nothing more than the giving of some special assistance to the dissolution and removal of fibrin." Further clinical investigation is needed to determine the question at issue. INFLAMMATION. 71 Assuming the systemic influence of mercury upon inflammation; its remedial operation can be insured only, by employing it in a certain class of cases, and with certain precautions. Both these practical requisites are generalized by Sir Thomas Watson, thus :— " In common adhesive inflammation, whether of the serous or areolar tissues; whenever, in fact, you have reason to think that coagulable lymph is effused, and mischief is likely to result from its presence, then you may expect benefit from the proper administration of mercury; as an auxiliary, however, to blood-letting, when blood- letting is indicated, not as a substitute for it..... Previous blood- letting renders the body more readily susceptible of the influence of mercury; and the operation of the mercury comes in aid of the salu- tary effects of the abstraction of blood. The two remedies accomplish by their joint power what neither of them might be able to accomplish singly." " On the other hand, mercury is likely to be hurtful in those forms of disease, where the morbid action approximates to its OAvn action; in cases of erysipelatous inflammation having a disposition to gangrene ; in scrofulous diseases; in inflammatory complaints attended with general debility, and an irritable condition of the nervous system, or a manifest tendency to take on a low and typhus-like character." On behalf of the scrofulous diathesis, it is added; that moderate salivation may prove salutary during an attack of common inflammation; and as surely in- jurious if the inflammation be scrofulous. " When we have to contend with acute inflammation, and desire to prevent or arrest the deposition of coagulable lymph, our object is, after such bleeding as may have been proper, to bring the system as speedily as possible under the specific influence of mercury." " We know that the whole system has been brought under the specific influence of mercury, as soon as its effects become even slightly perceptible in the gums and breath of the patient; and in adults we cannot be sure of it before. These symptoms are enough; you,need not in general look for any more decided affection of the mouth, such as ulceration of the gums, swelling of the glands beneath the jaw and the tongue, and a profuse Aoav of saliva..... All that is requisite is, that the gums should become distinctly tender, and that the mercurial foetor should be unequivocally manifest, and that these symptoms should be kept up for a certain time. Noav this is best effected, usually, by giving some form of mercury in equal and repeated doses by the mouth. For urgent cases, calomel is the best form in which it can be administered; two or three grains given every four or six hours, will generally suffice to touch the gums in the course of thirty-six or forty-eight hours. If it act as a purgative, its specific effect upon the whole system will be post- poned by that circumstance; and it then becomes expedient to combine it Avith just so much opium as will prevent it passing off by the bowels. A quarter of a grain of opium with two grains of calomel or a third of a grain of opium Avith three or four grains of calomel, will generally be sufficient to restrain the purgative operation of the latter. When a speedier effect is desirable Ave give larger doses; such as five or ten grains every three, or even every tAvo hours ; or we combine mercurial inunction Avith the exhibition of calomel by the mouth. It is impossible to lay down any precise rule that will fit all cases. Blue pill, or else the 72 GENERAL PATHOLOGY AND SURGERY. hydrargyrum cum creta, may, in certain cases, be preferable to calomel; but they must be given in greater quantity." ■ " Mercury is of great service in many cases of chronic inflammation; and I may repeat here the observation I formerly made when speaking of blood-letting—that the treatment must keep pace, as it were, with the disease. When textures have been slowly altered by a gradual deposition of coagulable lymph, we should gain little or nothing by suddenly or speedily salivating our patient. The lymph, if it can be dispersed at all, must be gradually taken up again : and mercury, given with the view of promoting its absorption, must be slowly and gradually- introduced into the system, and its specific influence, when at length it is felt, must be sustained for a considerable length of time." Certain evil consequences are apt to follow the use of mercury. In fact, the symptoms of systemic infection by this mineral have a general resemblance to those of constitutional syphilis, or systemic infection by the syphilitic virus. But as, in most cases, the unfavourable action of mercury is fairly attributable to its immoderate or prolonged adminis- tration—an error of rare occurrence, now-a-days—it is scarcely necessary to consider the treatment of mercurial poisoning. Profuse salivation is, however, an exception which merits attention. Some persons are very easily salivated. In one case—related by Dr. Farre—a lady was affected furiously, in a few hours, by two grains of calomel; prescribed as a purgative with some cathartic extract. She died at the end of two years, worn out, and having lost portions of the jaw by necrosis. Intense salivation is best relieved by the application of a few leeches to the swollen and painful glands. Smearing the gums with powdered tannin, will probably reduce their engorged con- dition, and give additional comfort. Gargling the mouth with weak brandy-and-water is another resource, not unfrequently successful in relieving the distress. Chlorate of potash, taken internally, is spoken of very favourably by Herpin, M. Ricord, M. A. Fournier, and Mr. Simon, as far as his trials of it have gone. The doses given were commonly ninety grains during the day; and it is expressly stated, that, while the inflammation of the mouth was thus effectually cured, the therapeutical influence of the mercury was in no degree diminished. On the other hand, some persons are very difficult to salivate. Such cases are not uncommon, and unfortunately they seem most apt to occur when the controlling agency of mercury is most urgently required. In syphilitic cases of obstinate resistance to mercurialism, Mr. Simon finds that this insusceptibility often gives way, if tartarized antimony be administered in conjunction for a day or two; a half-grain dose, and then a few quarter-grain doses at eight-hour intervals. Stimulants.—Wine, brandy, ammonia, or other stimulants, are necessary; whenever inflammatory fever has passed into a state of general depression and exhaustion, the natural sequence of nervous and Avascular excitement. Requisite, therefore, as stimulants may be in pro- portion to the weakness manifested at even an early period; they are sure to become indispensable as the fever itself subsides. And on account of the local condition also, stimulants may be appropriate. When, in the course of inflammation, productiveness predominates, in the shape of effusion and suppuration, it will be necessary to support the circulation under the demand then made; and when destructiveness INFLAMMATION. 73 predominates, it will be even more imperative to sustain all the vital poAvers under the influence of poisonous matters absorbed in the,course of suppuration, pyaemia, ulceration, or sloughing. The "genuine effects of stimulation " are thus generally enumerated by Dr. Anstie,* who has made this the subject of elaborate inquiry; but who, it must be confessed, has arrived at conclusions opposed for the most part to those of previous authors, and which are open to farther clinical investigation. The effects observed are eight in number:— " relief of pain ; removal of muscular spasm, tremor, or convulsion; reduction of undue frequency of the circulation ; reduction of excessive secretion; removal of general debility, or of special fatigue of the muscles, brain, or digestive organs; removal of delirium, or maniacal excitement, and production of healthy sleep; support of the organism in the absence of ordinary food; local increase of nutrition where this is deficient." In regard to one of these effects, at least,—" reduction of undue frequency of the circulation," this view of the action of stimulants would be antagonistic to the propriety and efficacy of administering them for the exhaustion consequent on inflammatory fever. If we would proceed yet farther, and endeavour to analyse the action of stimulants and interpret their operation, physiologically and therapeu- tically ; we encounter greater difficulties, and are led, at present, to the most irreconcilable conclusions. Pereira classes stimulants under the general head of neurotic remedies (acting upon the nervous system), and under the special class of Ganglionics (acting upon the sympathetic system). He adopts the definition of Dr. Billing ; " a stimulant is that which, through the medium of the nervous system, increases the action of the heart and other organs, by calling forth the nervous influence, or by facilitating the extrication of it in them." The definitions of Dr. Neligan,f and Dr. G. B. WoodJ—one of the authors of the " United States' Dispensatory," are both to the same effect. On the other hand, Dr. Anstie proposes ; " that the use of the word ' stimulant' be restricted to agents Avhich, by their direct action, tend to rectify some deficient or too redundant natural action or tendency; and, that agents which pro- duce excessive and morbid actions of any kind in the organism, be refused the name of stimulants, even though smaller doses of them may act in a truly stimulant manner. That, the word ' over-stimulation' be entirely rejected from use, as unphilosophical and a contradiction in terms"|| The kind and quantity of stimulant or stimulants appropriate, will vary greatly according to the age, constitutional strength, previous state of health and habits, of the individual. But the consideration of these particulars had better be left to the special experience and judgment of the practitioner. Tonics.—Cinchona bark, the mineral acids, sulphuric, nitric, nitro- muriatic, and other tonics; are useful under, perhaps, similar circum- stances to those requiring the aid of stimulants, in the treatment of inflammation. Y"et these two classes of remedial agents have different, perhaps opposite, effects, in some respects, although it is difficult to dis- tinguish their operation in every particular. * Stimulants and Narcotics, 1864, p. 113. f Medicines, their Uses and Modes of Administration, ed. 4, p. 348. X Therapeutics and Pharmacology, p. 48. || Op. cit., p. 161. 74 GENERAL PATHOLOGY AND SURGERY. A stimulant certainly produces its effects suddenly and transiently; a tonic, its effects more gradually and more permanently. Then again, the chief primary effect of the one, is to quicken the circulation, as mani- fested by increased rapidity of pulse; Avhile, the chief primary effect of the other, is to strengthen the circulation, and hence an increased force of pulse. Thus far these two kinds of agents contrast. Both, however, concur, in restoring the balance of the circulation from the depression connected with or consequent on the subsidence of inflammatory fever; and subsequently, in contending against the ex- haustion of continued effusion or profuse suppuration; or again, in overcoming the depression arising from absorption of poisonous matters, in the course of suppuration, pyaemia, ulceration or sloughing. The mineral acids seem to exercise a special influence on the secretion of the skin, and indeed, the secretions generally. After having administered the sesquicarbonate of ammonia, as a stimulant, with the tincture of bark or the disulphate of quinine, as a tonic, when first weakness super- venes ; the ammonia should subsequently be exchanged for,—say, the diluted nitro-muriatic acid; this tonic combination of bark and acid, being the most effectual means of restraining the sweats of hectic feArer, and of cleaning the furred tongue in gangrenous typhoid fever. The general improvement is often very remarkable, and permanent. Cod-liver oil, and nutritious diet, are naturally associated; the one seeming to renovate the power of assimilation, the other supplying the materials for restoration. Both become appropriate, and nutritious diet absolutely necessary, on the subsidence of inflammatory fever, and during hectic, pyaemia, and gangrenous typhoid fever; whether for the re- production of new blood and the general renovation of textural nutrition, or for the reparation of any local deterioration of texture, or loss of sub- stance, consequent on inflammation. Cod-liver oil may be regarded, partly, as a kind of food, supplying a limpid fat which passes easily into the circulation. In the first instance, it. is not unfrequently rejected by the stomach or bowels. Beginning, therefore, with a moderate dose, not exceeding a teaspoonful, of pale, transparent, inodorous, and almost tasteless oil, taken tAvice or three times a day ; this quantity may be gradually increased to a table-spoonful. It is best taken in a little milk, as an emulsion, or floating on orange-wine, ginger-wine, or other light cordial. The addition of a little diluted nitric acid is highly recommended by Dr. C. J. B. Williams ;* or if the tendency to nausea be extreme, the thirtieth or fortieth of a grain of strychnine in solution, with each dose of oil, will be found an excellent corrective. A further precaution is, that the oil be taken ten or fifteen minutes after a meal. The expression "nutritious diet," can scarcely be defined. It is assuredly the opposite to " antiphlogistic diet." Nutrition in the abstract, implies an adequate supply of all the proximate elements which form the textures and organs of the body; whereas the demand arising from inflammation must vary with the particular part affected. Nutritious food, of some kind, will be most needed in proportion to the supervention of suppuration, possibly profuse, and sloughing, possibly extensive. And experience, rather than any chemical knowledge, suggests an in- * Principles of Medicine, 3rd ed., p. 490. INFLAMMATION. 75 creased proportion of animal food, with a liberal allowance of ale or porter, as malt beverages, besides alcoholic stimulants. (b) Removal of the Local Consequences of Inflammation.—They are— productively,—effusion and its organization, suppuration, and the forma- tion of abscess; destructively,—ulceration, sloughing and mortification. As connected with inflammation, it would be unpathological to regard these local consequences othenvise than as continuations of this process ; terminally, it is true, yet continuations of one and the same process, essentially. The local remedial measures, therefore, which counteract the con- stituent elements of inflammation, are preventive of these after con- ditions. But the removal of inflammatory products yet remains to be con- sidered. By what special local proceedings can this indication be accomplished ? Two ways of removing any new product, or any former part of the body, are possible. By absorption, and by evacuation; the latter implying some operative interference. Effusion, consisting of serum, fibrin, and exudation corpuscles, may be dispersed by a stimulating embrocation of ammonia and olive oil, or of camphor and soap liniment; by mercurial ointments, such as the un- guentum hydrargyri nitratis ; by the compound tincture of iodine, or by " iodine paint;" and by spirit lotions. The influence of some of these agents is aided by the friction employed in their application. Pressure, uniformly applied by even bandaging, will also promote absorption; and this may be aided by some stimulating agent used conjointly, as Scott's ointment to an enlarged knee-joint. Absorption, is however, available only in chronic inflammation. Incision will be appropriate when the inflammation is acute, and accompanied probably with considerable tension, as in phlegmonous erysi- pelas. In all such cases stimulating applications are inadmissible ; both by reason of their nature, and the time required for their operation. Suppuration becoming inevitable in any case, the secretion of pus should be encouraged, by quickening the inflammatory process. Abstain- ing, therefore, from the further use of any remedial measures for coun- teracting inflammation; the formation of pus is best insured by warmth and moisture topically applied, as by a light poultice, or moist spongio- piline. Absorption of pus is possible. Serum, the fluid portion of pus, is thus readily removed. Pus-cells must undergo a preparatory change. They disintegrate and re-enter the circulation ; or remaining, in part at least, the broken-doAvn pus-cells aggregate and form a cheese-like matter, Avhich may at length become cretaceous. Instances of such absorption not unfrequently occur, and authentic cases are recorded by Messrs. Hilton, Birkett, and Critchett ;* and one by Mr. Lawrence.| The probability of absorption taking place, is but little available for any practical purpose. Abscess or a collection of matter, generally tends to point, and the surgeon should then folloAV the footsteps of nature. An incision, Avhenever and wherever pointing presents, and of sufficient extent to make a free opening for the evacuation of matter, and » Med. Times and Gazette, 1858, p. 295. f Surgery, Ed. by T. Holmes, vol. i. p. 142. 76 GENERAL PATHOLOGY AND SURGERY. its discharge as secreted subsequently; is the rule of treatment. Abscess in certain situations should be opened early; indeed, the surgeon cannot be too alert. Thus, in parts abounding with loose cellular texture, as the neck, axilla, groin, neighbourhood of the rectum and vagina, popliteal region, and generally in the cellular planes between muscles. So also suppuration underneath unyielding fibrous expansions, and in the sheaths of tendons. Then again, when adjacent to important organs; as the trachea, pharynx, thorax, abdomen, urethra, and joints. Abscess, more- over, arising from irritant matters; as by the extravasation of urine, or faeces, should be promptly set free. Abscess in situations less accessible, although urgent, perhaps, in other respects, requires some delay; as with regard to the lungs, liver, spleen, kidneys, and most internal organs. A dependent opening, in order to facilitate the after escape of pus, has been particularly recommended, rather than an opening in the situa- tion of pointing. But this practical injunction may be observed too absolutely; for wherever matter points, there, ultimately, an open- ing will take place. If necessary, (L however, a dependent counter- opening may also be made, to in- sure the ready discharge of pus as it forms. To discover the presence of pus, the mode of opening an abscess is important. By introducing a bis- toury perpendicularly, a drop of matter wells up along the side of the blade, or a half-turn of the instrument will enable it to do so. The puncture thus made is then readily converted into an incision of sufficient extent. (Fig. 6.) Thick and flaky pus, and especially when situated deeply, requires a proportionately more extensive incision. Extrusion of any texture, as muscle or fat, hindering the free evacuation of pus, may be obviated by inclining the blade of the bistoury, instead of withdrawing it, as the matter flows. Haemorrhage is usually slight and temporary. But in puncturing a deep-seated abscess, there may be some danger. Mr. Hilton, therefore, recommends that an incision be made through the integuments and fascia, so as to expose any muscle under which the pus lies; the cavity of the abscess should then be penetrated by a director, along the groove of which, as a guide, a slender pair of dressing forceps being introduced, the blades are opened, the muscular fibres separated, and free exit is safely given to the pus. Sometimes, the nature of a swelling or tumour may be doubtful; whether it be solid or fluid, and if the latter, whether an extravasation of blood, or an inflammatory effusion or pus. To clear up the diagnosis, before making an opening with a bistoury to discharge any such fluid matter, it may be advisable to introduce a grooved needle. (Fig. 7.) A INFLAMMATION. 77 drop of fluid wells up along the groove, or any solid organized material lodged in the groove is abstracted by withdrawing the needle; and either product can then be examined by the naked eye or under the microscope. I often have recourse to this procedure. Fig. 7. The admission of air is generally of serious consequence. Hence some precaution must be observed in opening any large and chronic abscess. A valvular aperture—as originally proposed by Abernethy—is the best safeguard. Having drawn the skin well to one side, a bistoury is introduced perpendicularly, as usual, but ere the matter has entirely ceased to flow, the integument is alloAved to regain its former position; thus obliquely overlaying the aperture in the cyst. The external opening no longer directly communicating with the internal, any matter will continue to drain aAvay without the ingress of air. Moreover, only so much pus escapes as may be discharged by the collapse of the walls of the abscess. When the cavity has partly refilled, the same operation is repeated, and as often as may be necessary for the cyst to contract securely and finally close. Whether an abscess be acute or chronic, small or large, any thumbing or squeezing would be an unpardonable injury to the delicately or- ganized and highly vascular lining membrane, which previously pus- forming should now become lymph-producing for reparation. On one occasion, having opened a large chronic abscess, situate over the gluteal region, I took the liberty of introducing my finger; deeming it advisable to do so, for the double purpose of turning out the uncommonly thick flaky matter, and of ascertaining Avhether the cyst communicated with dead bone ; the case, a rare one, having simulated either disease of the hip-joint or of the sacro-iliac. The subsequent escape of matter can, if necessary, be facilitated by the employment of a " drainage-tube," as recommended by M. Chas- saignac. It is a small indiarubber tube Avith lateral holes ; and this pipe may be passed into the abscess leaving one end hanging out, or drawn through the abscess by a counter-opening and both ends tied together. The objection to this proceeding, is the irritation caused by the tube, as a foreign body. In fact it is a seton. The dressing of an opened abscess should be unirritating. A light poultice may be applied to encourage the discharge of pus, during the process of granulation from within ; or the application of a piece of lint to close the aperture, as soon as possible, Avill be appropriate, when the abscess is to be reopened from time to time. Abscesses by " translation," and " secondary abscesses" in the course of pyaemia, should be treated as chronic abscesses; and the more so the larger the size to Avhich they have attained. A valvular opening there- fore should be made, and closed with a piece of lint after the tension of the sac is sufficiently relieved, this being repeated when necessary. Obviously such treatment relates only to external, or at least to accessible parts. Sinus and fistula require special treatment, in some respects. Any 78 GENERAL PATHOLOGY AND SURGERY. assignable cause having, if possible, been removed ; pressure by a graduated compress and bandage, Avill succeed occasionally in bringing about adhesion ; if the sinus or fistula be recent and accessible. When induration has taken place, or pressure cannot be applied; stimulating injections of sulphate of zinc or nitrate of silver, sometimes answer the purpose. Or a red-hot wire introduced up the passage, may prove suc- cessful. This is conveniently accomplished by Mr. Marshall's apparatus; whereby a platinum wire, introduced cold, is made red-hot instantaneously by the galvanic current. Generally speaking, however, sinus or fistula having become indurated, it obstinately resists any attempt to excite adhesion. Slitting up the passage with a curved bistoury, on a director if necessary (Figs. 8 and 9), and healing by granulation from the bottom, must then be had recourse to. A familiar illustration is the operation for fistula in ano. Fig. 8. Fig. 9. The destructive consequences of inflammation—i.e., ulceration and sloughing or gangrene, severally present certain indications of treatment. Ulceration—as depending on inflammation—may be arrested by counteracting any of the constituent elements of inflammation, which are still in operation. Local antiphlogistic treatment—including rest and an elevated position of the part, is indicated. During reparation, the process of suppurative granulation needs little or no assistance. Warmth and moisture, by means of a light poultice, or spongio-piline epithem, may be continued while the chasm is filling up; rest and position being still ob- served. Superfluous organizable material—pus, is discharged ; and when the granulations have grown to the level of the skin, and are no longer suppurative, the aid of a poultice may be discontinued. Water-dressing, simply to exclude the irritating action of the air, is then alone necessary. This application should be exchanged for some slightly stimulating wash, if the pale and flabby state of the gTanulations suggests the propriety of so doing. A weak solution of sulphate of zinc answers very well. The pressure of a bandage will aid its effect, and repress any exuberant growth. Sloughing and gangrene, are, in like manner, amenable to local anti- phlogistic treatment, with the view of arresting the process of destruction. Effusion—always an essential constituent of inflammation—is here the element, in particular, to be counteracted or its effect overcome. The relief of tension is imperative. Hence, incisions as free as may be neces- sary, are the primary indication of treatment. Its efficacy is witnessed in phlegmonous erysipelas and carbuncle. The process of separation of the living from the dead textures, must INFLAMMATION. 79 be encouraged. Warmth and moisture, by a poultice or spongio-piline epithem, or the more stimulating action of a yeast poultice, will be highly serviceable, both in limiting the sloughing and inducing the detachment of slough. The latter kind of poultice has the advantage of destroying the foetor of decomposing textures. Charcoal in powder, chlorides of lime or zinc, and carbolic acid, are also valuable antiseptic applications. It should, however, be remembered that any stimulant application may over-act, and by hurrying on the inflammation beyond that requisite for the ulcerative severation of textures, would cause the gangrene to spread. The line of separation having formed, the detachment of slough has yet to take place. During this period, its extraction prematurely would be attended with haemorrhage, perhaps considerable. Nature may be aided gently, from time to time, by slight manipulative interference, here and there. Finally, the removal of slough is an obvious indication which can hardly be overlooked. Dead soft textures are easily withdrawn by the finger or forceps, a sequestrum will require to be extracted from the encompassing sheath of new bone. The healing of soft textures, subsequently, is by granulation; and the treatment that for a simple healing ulcer. Thus ends the local treatment of inflammation, in its consequences, productively and destructively. The treatment of the concomitant constitutional disorders,—hectic fever, arising from suppuration, and the typhoid fever arising from gan- grene ; is represented by those constitutional remedial measures which come into use as the inflammatory fever declining, is succeeded by general Aveakness and excitement. Stimulants and tonics on the one hand, with opium; and a nutritious diet, constitute the resources referred to. Pyeemia, also, is amenable to this plan of treatment, if, indeed, it be subject to any remedial measures. Varieties of Inflammation. The excess or the defect, or it may be, the peculiar character, of one or more of the constituent elements of inflammation, gives rise to corre- sponding varieties. The principal are as follow :—sthenic and asthenic; acute, subacute, and chronic; phlegmonous ; congestive ; erysipelatous ; diphtheritic or pellicular ; haemorrhagic ; and certain specific inflamma- tions ; as the scrofulous, the gouty, and rheumatic, the syphilitic and the gonorrhoeal. The sthenic and asthenic varieties of inflammation, observes Dr. C. J. B. Williams, are referable to a difference in the strength and irri- tability of the heart and arteries, and in the quality and quantity of the blood which they propel. Sthenic inflammation is marked by a strong, hard pulse, high fever, very fibrinous blood, a full and active develop- ment of the chief symptoms of inflammation, and a tendency to the effusion of the more plastic products. Patients affected with sthenic inflammation require and bear more antiphlogistic treatment than others; and if used in time, such treatment is commonly very successful, for this form of disorder occurs in subjects of the most robust constitution, in whom therefore the effects of disease are most readily shaken off. Asthenic inflammation occurs in persons, the tone and real strength of whose vas- cular system is low, and whose blood, generally speaking, is poor. The pulse is not always affected ; but Avhen it is so, it is in frequency rather 80 GENERAL PATHOLOGY AND SURGERY. than in strength or firmness; the fever, if there be any, is of a slight, re- mittent, or low character. The products are either scanty, or of a cacoplastic or aplastic nature; or the effusion may be chiefly serous, the inflammation differing little from flux and dropsy. Acute, subacute, and chronic inflammation properly relate to its_dura- tion, but these terms are often used as synonymous with sthenic and asthenic. Acute inflammation may be, and commonly is, sthenic, but its distinctive character is, that it tends to a speedy termination of some kind or other. It may end in resolution, effusion, suppuration, or gan- grene, in a period varying from a few days to three weeks. An in- flammation lasting above the latter period is termed subacute, and if protracted beyond six weeks is properly called chronic. The latter is commonly asthenic, though it sometimes presents a good deal of the sthenic character. Acute inflammation, when at all extensive, is attended with considerable fever and constitutional disorder. With subacute in- flammation the fever is less, and may even be absent. In chronic inflammation there is rarely much fever, and when present, it is of a remittent or hectic kind. The products of acute inflammation are commonly copious and dis- tinctive, being either free coagulable lymph or pus. Chronic inflamma- tion results chiefly in pus-formation, or in contractile lymph-deposit; while in subacute inflammation, the products are often of intermediate nature, as purulent lymph, or curdy matter. Phlegmonous inflammation is illustrated in the phlegmon or common boil of the skin. Its chief feature consists in its being abruptly cir- cumscribed by an effusion of solid lymph, which brings the inflammation to a termination, either by suppuration, or by sIoav subsidence, as in blind boils. A highly fibrinous condition of the blood contributes to render inflammation phlegmonous, but this form of inflammation is com- monly exhibited by cellular and parenchymatous textures. The type of phlegmonous inflammation is usually sthenic ; and even when it advances to suppuration or sloughing, it defends the system against the noxious influence of the pus and dead matter. Hence, the fever is inflammatory, and the local pain, irritation, and heat, are considerable. Congestive inflammation is that in which the accumulation of the blood in the vessels of the affected part, and retardation of its movement, predominate over the determination of blood. Hence it is commonly asthenic, and generally originates from causes that produce congestion, the reaction which converts this into inflammation being imperfect or partial. Its symptoms are less prominent than those of more active inflammation, and partake more of the character of congestion. There may be little pain, heat, or fever; but the redness, Avhere visible, is more marked and deeper than usual, and if the affected organ be very vascular, as the liver, lungs, and kidneys, the swelling may be considerable. Congestive inflammation is usually subacute or chronic, not tending to speedy results; but a kind of flux or dropsy may occur early, as happens from congestion. The solid effusion ensuing is gene- rally cacoplastic; thence the consolidations or indurations resulting, are often of a dense indolent kind, tending to contract or to degenerate still further into aplastic matter. Inflammation of the lung supervening on disease of the heart, on bronchitis, and on asphyxia, is generally congestive; and so is inflammation of the liver, as arising from any cause. TUMOURS OR MORBID GROWTHS. 81 Erythematic or erysipelatous inflammation contrasts with phlegmonous in its tendency to spread, OAving to its not being attended with the effusion of plastic lymph. In its severe form, it is accompanied by much redness, pain or smarting, heat and swelling; the effusion is chiefly serous or sero-purulent, and often raises the cuticle in blisters. It may terminate in resolution ; but in its Avorst form, it terminates in diffused suppuration, sloughing, or gangrene. The fever is asthenic, or even typhoid. Diphtheritic or pellicular inflammation of mucous membranes is some- what allied to the erysipelatous, being diffused and spreading, generally asthenic, and accompanied with a low kind of fever. But it is attended with more soreness than pain, little swelling, and a deep redness, which is early obscured by a characteristic film of grayish or dirty-white albuminous matter, exuded on the inflamed surface. Patches of this kind often occur on the tonsils in sore throat, resembling sloughs. In scarlatina sometimes, diphtheritic inflammation affects the whole throat, and extends even to the trachea and bronchi, and into the mouth and gullet. The films of lymph effused are often foetid, apparently from incipient decomposition. Hemorrhagic inflammation is attended with effusion or extravasation of blood, in a greater or less degree. It occurs in subjects, scorbutic or affected with purpura, and in connexion with disease of the liver or kidneys. Thus, Dr. C. J. B. Williams has met with several instances of haemorrhagic pleurisy and pericarditis in conjunction with cirrhosis of the liver, and Bright's disease of the kidney. The specific inflammations will be fully described under their different designations, among Blood-diseases. Treatment.—The treatment of the leading varieties of Inflammation is sufficiently indicated in the general course of treatment relative to Inflammation. • CHAPTER II. TUMOURS OR MORBID GROWTHS. Morbid Growths present certain general characteristics, in respect to their structure and vital endowments, which may be advantageously noticed, before describing the various species of groAvths. 1. In common with all other Morbid Products, Morbid Growths are products supplemental, in the sense of being additional, to the parts of- the body in which they occur. 2. In their textural structure, and in their physical properties, Growths, generally resemble the various healthy tissues, in Avhich they severally originate. There is a structural homology or at least analogy between the two; and their structural elements are similar if not identical. But GrOAvths, in common with other organized Morbid Products, do not generally attain to the same state of textural development as healthy tissues- they so far represent structural retrogressions of the normal tissues to various rudimentary conditions, by arrests of development of their structural elements. [P. p. 93.] In their decree or grade of organization, GroAvths represent states of a 82 GENERAL PATHOLOGY AND SURGERY. textural structure, at least as highly developed as the False tissues pro- duced in the Reparation of Injuries or resulting from Inflammation ; yel Growths are sometimes regarded as still further deviations from the organization of normal or healthy tissues. 3. A Growth generally presents a well-defined boundary, often a distinct capsule, by which the included structure can be readily dis- tinguished circumferentially from adjoining textures. By virtue of their structural homology or resemblance to healthy tissues, Growths may perhaps be regarded as hypertrophies or over- groAvths, but as discontinuous from the surrounding tissues; while, by the latter character, they are distinguished from out-groAvths or hyper- trophies continuous with the adjoining tissues—e.g., out-groAving portions of the thyroid and prostate glands. 4. The vital poAver of GroAvths is peculiar, and exhibits their essen- tially morbid character. They possess the inherent poAver of reproducing their oAvn structural elements, Avhen adequately supplied Avith blood or plasma as the nutritive material suitable for their production. Hence, I would designate Morbid Growths, products of Reproductive Nutrition. They thus increase and multiply. But, another vital characteristic is this; they apparently fulfil no useful purpose in the animal economy. " It is not," observes Mr. Paget, "in the likeness or in the unlikeness to the natural tissues that we can express the true nature of Tumours, it is not enough to consider their anatomy, their physiology also must be studied; as dead masses, or as Growths achieved, they may be called like, or unlike, the rest of a part; but as things groAving, they are all unlike it. It is, therefore, not enough to think of them as hypertrophies or over-growths; they must be considered as parts overgroAving, and as overgrowing Avith appearance of inherent power, irrespective of the groAving or maintenance of the rest of the body, discordant from its normal type, and with no seeming purpose." Such are the general structural characters, and such the general vital endoAvments of Growths, or Tumours. But the vital changes of certain Growths contrast remarkably with the progress of others. Some appear to exercise a merely local and mechanical influence; their pathological significance is limited to surrounding parts, which are variously pressed, obstructed, and, possibly, obliterated by absorption. Inflammation, suppuration, and ulceration occasionally occur in parts around, owing to pressure of the tumour, and thus a pendulous growth, more especially, may protrude. Otherwise, the healthy mechanism only of the part becomes impaired by these localized Growths. Moreover, Avhen completely extirpated, as by the surgical operation of excision, they never return. Other Growths are localized, but they are also recurring ; returning in situ, even again and again, when ap- parently completely extirpated. And yet other Growths are recurring but not localized; they gradually pervade surrounding tissues, and affect neighbouring lymphatic vessels and glands; they are prone to undergo ulceration, and by extension of this process thus destroy ad- jacent parts. They propagate also in different, and distant regions of the body, and grow in succession and with increasing rapidity. GroAvths having these vital characters, are aptly denominated infiltrating (Walshe) or malignant,—a less expressive term; Avhile all other GroAvths being distinguished by the negation of this generic attribute, are non-infiltrating, or innocent comparatively speaking. TUMOURS OR MORBID GROWTHS. S3 According to the foregoing distinctions, Morbid Growths may be classified as follows :— Localized Growths (non-infiltrating). Cysts. Simple or Barren. Serous. Sanguineous. Synovial. Mucous. Oily. Colloid. Seminal. Compound or Proliferous. Cystigerous. Glandular. Cutaneous. Dentigerous. Cystic Tumours. Fatty Tumour. Steatoma. Fibro-cellular Tumour. Painful Sub-cutaneous Tubercle. Neuroma. Fibrous Tumour. Fibro-calcareous. Fibro-cystic. Recurring Varieties. { Fibro-nucleated | Recurring Fibroid. Cartilaginous Tumour. (Enchondroma.) Varieties. Recurring Varieties. I ^eloid; (PaSeTfc> ,or ( Fibro-plastic. Lebert.) Vascular or Erectile Tumours. Aneurism by Anastomosis. Osseous Tumours. Glandular Tumours. Infiltrating Growths. Cancer. Encephaloid. Varieties.—Villous. Melanotic. Fungus Haema- todes. Scirrhous. Varieties.—Osteoid. Colloid. Varieties. Cystic Cancers. Epithelial Cancer. Varieties. General Indications of Treatment.—In accordance Avith the general pathology of Morbid Growths, and their relations to the developmental anatomy of healthy Tissues, certain general indications of treatment are deducible. 1. To reduce the structural condition to a loAver degree of retro- gression,—by degeneration or by disintegration, in order to facilitate absorption of the Tumour. Medicinal agents, and local appliances, e. g., stimulating applications, compression, may fulfil this indication. 2. To superinduce some other morbid process, in situ, for the direct suppression of the Growth, and its obliteration or destruction as a Tumour. Inflammation, or Sloughing; by stimulant injections, setons, caustics, congelation, may fulfil this indication. 3. To remove the Tumour, as such, mechanically, by surgical opera- tion ; puncture, enucleation, ligature, excision, amputation. Special Tumours.—Morbid GroAvths are severally distinguished by differences or peculiarities, in respect to their structural condition, and physical characters of shape, size, weight, consistence, colour, situation, and number produced ; and by their vital history of origin, including, a 2 84 GENERAL PATHOLOGY AND SURGERY. Fig. 10.* hereditary predisposition and relations to age and sex; causes—constitu- tional and local; course, and consequences. In other words, GroAvths have differences of character—pathologico-anatomical, physiological and pathological, in regard to species. These differences I proceed to de- scribe, and to consider in the diagnosis, etiology, and prognosis, of the various kinds of Tumours, as arranged in the foregoing table. The special Treatment of each will also be described, in illustration of the general indications already enunciated. Cysts, and Cystic Tumours.—Structural Condition.—This is very varied. (1) Cysts. " Essentially, this species of growth," observes Paget, is " a cyst, sac, or bag, filled with some substance which may be regarded as entirely, or for the most part, its product, whether as a secretion, or as an endo- genous growth." This cyst (fig. 10), sac, or bag, is either soli- tary, or frequently aggregated with others; and each may be free and moveable, or imbed- ded in the substance of some H other growth, thus forming a "cystic tumour." But the con- tents of the cyst or cysts are the chief features of distinction. Some contain fluid unorganized secretions, and are spoken of as simple or more correctly, barren cysts. Fig. 11.+ Others contain organized, endogenous growths, and these are denominated compound, or more appropriately, 'proliferous cysts. (Fig. 11.) But the simple sac is the type, from which the proliferous cyst may be re- garded as a departure to a more complex condition; and between the former in its simplest con- dition of development, and the latter in its most anomalous condition, each intermediate variety may be distinguished by the contents of the cysts, and the whole arranged in a tolerably even series of pro- gressive organization. a, f^r^XSSl lfZ!°{ (%i5rwith vei7 ™** wal,s- part ofTeTZrVrL\?Zm&ZglavdrA ^^ iT°Wth i8 SeeD attacl^ <» similar grow h mS St IWlnl/ ^V",* s™ller,C?st nearl? fil^ with a (Paget.) Bartholomew s hospital. Three-fourths the natural size. TUMOURS OR MORBID GROWTHS. 85 Simple Cysts.—A cyst is formed of fibro-cellular tissue, but without an epithelial lining. This is present in the more finished cysts, and is usually the tessellated variety of epithelium. A more perfect secreting surface is thus prepared, and the varieties of simple cysts take their names from the nature of their secretions—their contents. Thus we recognise the serous, sanguineous, synovial, mucous, oily, colloid, and seminal cysts. These barren cysts may be found in almost any part of the body— and to this subject I shall have occasion again to refer in connexion with the origin of cysts—but the seminal cyst has, so far as I am aware, been found exclusively attached to the spermatic cord, and by virtue of the spermatorrhoea which it contains, may be regarded as on the verge of that higher organization which characterizes the proliferous cyst. Proliferous Cysts.—The organized growths within a proliferous cyst are sometimes simple cells, detached, or pedunculated and attached to the interior of the cyst whence they have sprung. Thus are formed the com- mon cystigerous ovarian tumours. Occasionally the sub-cysts are found imbedded in the walls of the parent-cyst, or even projecting from its external surface, so as almost to appear of exogenous formation. This mode of cyst-formation is, I think, illustrated by inference from Dr. Mettenheimer's observations on the structure of the common hydatid mole, or cystic disease of the chorion; but for the details of this supposed process the student is referred to Mr. Paget's Lectures. Glandular proliferous cysts are so named from their containing some kind of organized substance or substances, the structure of which resembles some kind of healthy gland-tissue, and for the most part that in which the cysts are imbedded. The thyroid and mammary glands, and perhaps the prostate and labial glands, are the chosen seats of this sjjecies of cyst. But a glanduliferous cyst may be developed without any connexion with a secreting gland. A tumour of this kind was removed by Mr. Paget from beneath the gracilis and adductor longus muscles of a woman twenty-five years old. The patient remained well at the end of more than three years afterAvards. * A similar case and operation occurred to Mr. LaAvrence. Cutaneous proliferous cysts are so called from their structure consisting of, or containing skin or its remains, Avith hair, or other forms of epidermic tissue, and fat. These cysts are not necessarily confined to the skin, as sebaceous and atheromatous tumours or Avens, but are more commonly found in ovarian tumours ; and, very rarely, in the testicle, lung, kidney, bladder, sublingual tissue, and within the skull. Teeth may also be discoArered Avithin capsules- in abnormal situations, as in ovarian tumours, and the jaAvs; and such capsules have received the name of dentigerous proliferous cysts. Diatinosis.—The distinctive characters of cysts are chiefly physical; their diagnosis from all other tumours being an application of pathological anatomyrthrough the medium of Physical Signs. [P. p. 224.] A simple or barren cyst, Avith its fluid contents, necessarily implies a circumscribed and fluctuating tumour, or the resistance only of fluid pressure. Such are cysts,—serous, sanguineous, enlarged synovial bursae, adventitious "-anglia, often seen on the back of the wrist, mucous cysts,— e a. surcharged Nabothian follicles about the neck of the uterus, or distended Cowper's glands just Avithin the orifice of the vagina, the less * Op. cit., vol. ii. p. 74. 86 GENERAL PATHOLOGY AND SURGERY. fatty cysts,—e.g., certain wens, and seminal cysts in connexion with the spermatic cord—encysted hydroceles. A collection of such cysts presents similar characters; the resistance of the circumscribed fluctuation varying in degree, from that of the most fluid, to that of the most solid-feeling thick fluid; as grumous blood, synovia, mucus, or the butter-like con- sistence of sebaceous cysts. Subject to these original deviations, the typical condition of the cystic- growth is that of one or more membranous bags, filled with some kind of fluid ; and, as such, its physical characters supply a complete diagnosis, both in respect of exactitude and earliness. An equivocal diagnosis can be determined by puncturing the supposed cyst with a grooved needle or with a fine trocar and canula, and examining its contents, simply by in- spection, or under the microscope. Other conditions—not deviations—are exceptional and subsequent productions :— The proliferous development of a solid groAvth within a parent-cyst, is an occasional event; especially observed in sero-cystic disease of the breast, and in cystic bronchocele. A tumour, originally fluid and fluc- tuating, is thus converted into an unbroken solid mass; but during this transitional change, the growth, not yet completely filling the cyst or cysts, is immersed in fluid, so that the whole feels a mixed tumour— partly fluid, partly solid. Ultimately, if one of the cysts should burst from over-distension, or if it be artificially laid open, the growth within, no longer restrained, increases, and protruding in the form of a fungus, gives to the tumour a new and characteristic appearance. Varieties.—A thickened cyst simulates the characters of other tumours. It may resemble a chronic abscess—i.e., without the pain, heat, and redness of inflammation, only presenting swelling Avith fluctua- tion. But a pus-cyst, so to speak, is more blended with surrounding tissues,—it is less circumscribed than a cyst which has merely become thickened. Or, an ordinary cyst is sometimes actually converted into a painless chronic abscess. Their diagnosis is then comparatively unim- portant. This also is an occasional and subsequent condition, and one, therefore, not affecting the exactitude and earliness of the diagnosis by physical characters. The sufficiency of the physical method still prevails. (2) Cystic-tumour.—A cyst or cysts within the substance of a solid tumour—renders the diagnosis more obscure ; but its equivocal character varies with the particular kind of tumour and the thickness of the inter- vening substance. Cysts are, occasionally, set in the substance of a fibrous, fatty, or cartilaginous tumour, and perhaps no kind of tumour is exempt. The depth of integuments, underneath which a cyst may be situated, Avill more completely conceal its true character. Apart, however, from exceptional and secondary conditions, the phy- sical signs of cysts are constant. A .circumscribed boundary, and fluid resistance, in some degree, to the touch, invariably accompany and announce the presence of a cyst or collection of cysts. These characters are also peculiar ;—they point to no other kind of tumour or swelling, except in the cases adverted to. Moreover, they are readily perceived by clinical examination. Situation.—Cystic growths—originating from the erring development of cells or nuclei—may occur in any texture or organ, but most fre- TUMOURS OR MORBID GROWTHS. 87 quently in the kidney, thyroid gland, mammary gland, choroid plexus, chorion; in the neck, gums, about the sheaths of tendons at the wrist,— forming ganglions; and about the epididymis, as seminal cysts, encysted hydroceles or hydroceles of the spermatic cord. (Paget.) Cysts having this origin are single, or numerous, in the same organ or part. Origin.—Of Simple or barren cysts: the serous date from birth or earliest childhood, as by transformations of naevi; or from puberty or later life, as an ovarian tumour by enlargement of Graafian vesicles ; or from perhaps still later life, as mammary cysts which begin during or after the time of natural degeneracy of the milk-glands. Of Proliferous cysts : the cutaneous which occur in or near the orbit, are congenital; Avhereas those Avhich, as Avens, occur in the scalp, are not congenital. They are, how- ever, hereditary, though unconnected Avith any constitutional tendency. Cyst-formation, whether barren or proliferous.—Three modes of production are tolerably Avell established ; but no accurate classification of these groAvths can be determined upon this ground of distinction. Cyst- formation is as follows ;— Firstly.—By the dilatation and coalescence of the spaces in cellular tissue, a rude cyst is formed, and afterAvards finished off on its internal surface, which becomes smooth, and perhaps lined with epithelium. Thus are formed certain adventitious bursae—e.g.. the little sac which Hunter first pointed out underneath the skin of an old corn. The simple cyst fashioned from areolar tissue may acquire a proli- ferous power, as Avitnessed occasionally in adventitious bursae, from the inner surface of Avhich pendulous little polypi sometimes grow. Secondly.—By the dilatation and distension of certain natural cavities. Of this kind of cyst are those sacculated enlargements of the lactiferous tubes, filled Avith milk or serum, Avhich Sir B. Brodie first described as sero-cystic conditions of the mammary gland. But this disease is perhaps more usually due to another mode of cyst-formation, Avhich I shall describe presently. The mode of production now referred to may give rise to cysts in many parts of the body. For example, natural bursae sometimes enlarge, and become distended Avith synovia. The bursae betwixt the skin and patella thus enlarged, and knoAvn as " housemaid's knee," is a familiar example. Mucous cysts, by enlarge- ment of the Nabothian gland-follicles about the cervix uteri, or of CoAvper's glands in the female, situated just within the vagina, are further illustrations of cyst-formation by dilatation and distension of a natural cavity with its OAvn fluid- Fat-cysts are produced in this way, out of the sebaceous and hair follicles, forming common Avens. Graafian vesicles by overgrowth, are evolved into ovarian tumours. I may here notice certain rare kinds of sanguineous cysts, Avfiich, from a case related by Mr. Pao-et, appear as he says, to be "dilated portions of blood-vessels shut off from the main streams." Of sanguineous cysts thus formed, one Avas removed by Mr. Lloyd some years since from a man's thigh. It lay in the course of the saphena vein, but neither that nor any other con- siderable vein Avas divided in the operation, or could be traced into the cyst. This cystVas of spherical form, about an inch and a half in dia- meter and completely closed; its Avails Avere tough and polished, on their inner surface, it was full of dark fluid blood, and its venous character Avas manifested by two valves, like those of veins, placed on its inner surface. On one of these a soft lobed mass, like an intracystic 88 GENERAL PATHOLOGY AND SURGERY. growth is seated. The preparation is in the Museum of St. Bartholomew > Hospital. , This specimen teaches an important lesson ; that a simple cyst formed by the expansion of a natural cavity, may become proliferous, and this truth is confirmed by the proliferous power of the lactiferous tubes when enlarged in certain cases of sero-cystic disease of the breast, and the prolific growth of cells in the parent-cysts of an ovarian cystic tumour. Thirdly.—Besides these two modes of cyst-formation, another mode of production has been discovered, chiefly by the observations of Roki- tansky,* Frerichs,y and Mr. Simon,} respecting cysts of the kidney. It would appear that certain cells expand and develop themselves into larger cells, Avhich aggregate together in " nests," each nest becoming enveloped with a thin capsule of fibro-cellular filaments, which thus forms a cyst containing cells.|| Fig. 12 But the erring cells themselves may each acquire sufficient size to merit the name of a cyst. The cells which naturally inhabit the villi of the chorion, according to Dr. Mettenheimer,^f occasionally enlarge into cysts, and form the hydatid mole. From erring cells are sometimes pro- duced serous cysts in the neck, in the thyroid body, in the gums, in the mammary gland, and a cystic condition of the choroid plexus. By this mode of origin, also, may be evolved certain sanguineous cysts,—e.g., in the neck; certain adventitious synovial bursae,—e.g., ganglions formed in connexion Avith the sheaths of tendons; and certain seminal cysts. (Paget.) * Ueberdie Cyste. Wien, 1850. + Ueber Gallert—oder Colloidgeschwiilste. X On Subacute Inflammation of the Kidney : Med.-Chir. Trans., vol. iii. II Proliferous cyst-formations from the cortical substance of the kidney, as a sequel to Bright's disease.—a, the fibrous sheath in progress of development out of d, the elongated and caudate nuclei coursing around the parent-cyst or aggregation of parent- cysts. They eventually break up into the requisite fibres, e is to represent the point- molecule, within an amorphous blastema, out of which the nuclei (b) form. They are at first spherical, afterwards elongated, and ultimately broken into fibrillation. This constitutes the " alveolar type or arrangement." 90 diam. (Kokitansky.) • Muller's Archiv, 18o0, H. v. p. 417. TUMOURS OR MORBID GROWTHS. 89 A surprising proliferous poAver is frequently manifested by cysts derived from erring cells, of which some instances of cystic diseases of the breast and other glands are probably illustrations. Associated with this power of growth and development, is the well-knoAvn fact, that proliferous cysts frequently recur after, as it would appear, the complete extirpation of the original cyst. Mr. Paget relates a remarkable case of this kind, recorded by M. Lesauvages.* The patient was sixty-three years old. The first tumour of the breast, of great size, was extirpated in February, 1832; a second appeared, and Avas removed before the healing of the first wound; a third in May; a fourth in September of the same year; a fifth sprang up, and was removed in February, 1833; a sixth in the ensuing May ; by a seventh operation, in June of the same year, three tumours were again excised; but from the same spot tAvo more arose, which grew rapidly, and the patient died. Course.—The vital career of cysts, and cystic tumours, is sufficiently indicated by the proliferous changes which cysts, originally barren, may undergo, and their issue, in the protrusion perhaps of the intra-cystic growth. The rate of growth of cysts, and the probability of their recur- rence, when removed, or apparently obliterated, vary considerably. Thus, of Simple or barren cysts ; the serous and sanguineous, observe no definite rule of increase, and neither, per se, are likely to return. A mucous cyst is more difficult to obliterate, and long after apparent cure, may fill again. Of Proliferous cysts; the cystigerous may be slow grow- ing, as an ovarian tumour, and not liable to recurrence, so also cutaneous cysts—as scalp wens; but cysts proliferous with vascular growths, may grow rapidly, as in the mammary gland, and very frequently return, even repeatedly. Treatment.—Cysts, and Cystic Tumours are amenable to treatment, in accordance with the general indications, 1, 2, and 3. Simple or Barren Cysts, containing unorganized secretions of various degrees of fluid con- sistence, may be effectually reduced by absorption, destroyed, or removed, by one or other of the following modes of treatment:— Stimulating applications, as the compound tincture of iodine, may in- duce absorption of the contents of the cyst; and if no re-secretion ensues, a cure will thus be effected. Puncturing the cyst, and drawing off its contents, folloAved by compression by means of a pad of lint and bandage ; is also a curatiAre proceeding of at least a temporary character. But the cyst is apt to fill again, eventually. By this treatment, I succeeded for some time, in controlling tAVo large cysts deeply situated, one beneath the muscles of the calf, the other deep in the popliteal space. The diagnosis also, in these cases, was determined by the preparatory puncture. Puncture, and a stimulant injection, or the introduction of a seton ; may succeed in obliterating the cyst by adhesion of its interior, or destroying it by sloughing, and in either Avay effecting a cure. Excision of the cyst, is a procedure available Avhen other resources have failed, or more advantageously in the first instance, before the tex- tures have been tampered with by any other treatment. A cyst may have become converted into a painless chronic abscess. I once removed a laro-e cyst, in this condition, from beneath the tensor-vaginae and sartorius muscles, by an incision eight inches long. The man made a good recovery. [P. p. -oo-J Complete excision is rarely necessary to ensure * Aitliiv. Gen. de Medeciue, Fevrier, 1S44, p. 186. 90 GENERAL PATHOLOGY AND SURGERY. the non-recurrence of any simple cyst; a small portion left after opera- tion, will granulate and cicatrize. But a cluster of cysts must be removed entirely; otherwise, any one remaining will aftei'Avards continue to grow. Thus, the whole mammary gland, if beset Avith cysts, must be sacrificed. Proliferous Cysts.—Excision is the only sure and safe mode of treat- ment ; removal of the cyst or cysts entirely, by the knife, being necessary to overcome the productiveness of any such cyst. Cystigerous, and glandular, proliferous cysts, the latter especially, render this proceeding the more necessary. Cutaneous proliferous cysts also are more properly excised. The common scalp-wen, for example, in most instances ; and the operation in this case is very readily accomplished. An incision hav- ing been made extending down through the cyst, either half can be seized Avith forceps and easily turned off its bed, the cellular connexion offering very slight resistance. Erysipelas is apt to follow this simple operation, in old or debilitated subjects. It may, therefore, be advisable in such cases, to remove the contents of the cyst by puncture, or even to destroy the cyst by sloughing. If the former mode of treatment be adopted ; the introduction of a probe through the small black point existing in most cases, will permit the contents to be squeezed out of the cyst. Avhich may then be made to heal from the bottom, by the substitution of a feAv threads as a seton. Or if it be desirable to induce sloughing of the cyst, this can be effected by introducing a stick of caustic potash, and turning it about a feAv times, or by pencilling the skin over the cyst. In either way the cyst is laid open when the slough separates, and heals, from within. Nitric acid and other powerful irritants are useful for the same purpose. Fatty Tumour.—Structural Condition and Diagnostic Characters.— This groAvth is of soft doughy consistence, defined or circumscribed, deeply and largely lobulated (Fig. 13), and freely moveable ; sometimes shifting from its original locality owing to the looseness of its connexion; often attaining to a large size and great Aveight, even to fifty pounds; usually Fig. 13.* Fig. 14.+ subcutaneous, and probably situated somewhere about the trunk, pos- teriorly, and solitary. It has the composition and general structure of ordinary M—i.e., fat-cells (Fig. 14), collected together, and imbedded in a fibrous mesh-Avork, more or less abundant, and resembling condensed cellular texture; this, however, is continuous with a thin fibro-cellular * Fatty tumour, removed from under the tongue ; half size. (Liston.) + Structure of a fibro-fatty tumour, a. Isolated cells, showing stellate crystals of margaric acid. (Bennett.) TUMOURS OR MORBID GROWTHS. 9] capsule enclosing the tumour ; prolongations of which, penetrating the mass separate it into lobes, while, externally, the Avhole investment is loosely connected with surrounding parts. Blood-vessels, coUected mostly at one point of the tumour, pass into its substance from the cellular capsule. Varieties.—Occasionally, the cellular capsule is thick, dense, and fibrous. Its prolongations may also become fibrous and firm. The Avhole substance of such a tumour is hard and comparatively immovable, and although still circumscribed and lobulated, resembles a fibrous tumour. The lardaceous variety is of this description. Hard fibrous knots, as of the fibro-cellular stroma, or even bony nodules, can, occasionally, be felt within a tumour, otherwise fatty. Or the mass may be, or become, softer than usual. Oleaginous fat, with but slight fibro-cellular parti- tions, presents the characters of a bag or cyst of fluid, and gives out the physical signs of a fluid encysted tumour. True cysts are, occasionally, developed in a tumour otherwise fatty; thus giving the consistence of roundish elastic bags of fluid set in a doughy substance. Still more rarely, suppuration occurs, centrally perhaps, within a fatty tumour, and forming a chronic abscess, simulates the character of a cyst. Lastly, the characters of any such tumour, purely fat or mixed, may be obscured by the depth of integuments beneath which it lies buried. But all these conditions are exceptional, and, excluding that of the occasional depth of the tumour, they are subsequent conditions also. Neither, therefore, will scarcely affect the exactitude and the earliness of diagnosis, by physical signs; the ordinary physical characters of fatty tumour being generally present, and exclusively indicating this kind of growth and no other morbid condition. Steatoma—a lard or suet-like variety of fatty tumour—is liable to occur in whatever part of the body this growth makes its appearance ; but steatoma has been found in some parts more especially; among them, in the mesentery, testicle, and mediastinum. (Walshe.) Fatty tumour is usually a solitary growth; but in exceptional cases, several may co-exist from two or three, up to as many as a hundred, or more. Situation.—Fatty tumour most commonly occurs in the subcutaneous adipose texture, especially of those parts where fat normally abounds in the healthy state, and is liable to accumulate ; as about the trunk—e.g., on the back, neck, and shoulder; also over the buttock, and the thigh; between the peritoneum and abdominal walls, escaping from which by the abdominal rings, it forms fatty hernia, so called. (Walshe.) This kind of tumour occurs more rarely in synovial sacs, especially that of the knee-joint, the " lipoma arborescens " of Miiller. It sometimes forms Avhere fat is normally scanty, as beneath the hairy scalp; or, Avhere fat is normally absent; as in the sub-mucous cellular tissue of the stomach, the intestine, the bronchi; in the sub-serous cellular tissue of the pleura or dura-mater, and beneath the investing membranes of the ventricles. Also in the substance of organs; especially in the lungs, liver, kidneys, and in bone " affected Avith osteoporosis and eccentrical atrophy." (Rokitansky.) BetAveen the corpora albicantia and optic nerve, in one ease. (Miiller.)* A fatty tumour, the size of a mushroom, was found between the arachnoid and dura mater, on the level of the fourth lumbar On Cancer, p. 153. 92 GENERAL PATHOLOGY AND SURGERY. vertebra. (Albers.)* One as large as a walnut, in the walls of the vena portae. (Andral.)f Origin.—Fatty tumour is very rare in children, but not unfrequently begins in youth, though, growing slowly, it may be overlooked for many years; it may begin to grow at any later age, but very seldom appears first in old age. This kind of tumour scarcely ever seems to be hereditary. Sometimes it has so appeared after fever or some general illness, as to seem due to a constitutional cause. It is sometimes referable to local causes, as a blow, or, more commonly, frequent friction, as by a strap or band over the skin. But in the majority of cases, no good cause Avhatever can be assigned. Course.—The influence of a fatty tumour is purely local and me- chanical. The rate of growth is generally very slow, sometimes fitful, very rarely rapid. It does not return, even when partially removed. It is not liable to ulcerate, but I have seen ulceration of the skin, appa- rently resulting from weight and friction, in the most dependent part of a pendulous fatty tumour in the thigh. Treatment.—Absorption of a fatty tumour is perhaps possible, under the influence of medicinal, treatment. Thus, this kind of growth is said to disappear occasionally under the influence of liquor potassae, adminis- tered in half-drachm doses, gradually increased to a drachm, and con- tinued for a month or more. In one case, the tumour was sensibly diminished in size by this mode of treatment, which was originally tried by Sir B. Brodie. J Excision, as a rule, is the only successful treatment. It is rendered necessary by the large size to which a fatty tumour generally attains ; and especially when the mass is so placed—which, however, is not generally the case—that by its further enlargement, it would encroach on important parts adjacent, thereby rendering the operation eventually difficult or impracticable. The freedom with which a fatty tumour shifts its place, owing to the loose cellular connexions of its thin dry capsule, is an additional reason for timely performance of the operation. I have thus had occasion to remove a fatty tumour from the cheek from the shoulder overhanging the axilla, and from other situations! lhe operation itself, although perhaps extensive, is easily performed. Dissection, even among parts of anatomical importance, is scarcely requisite. The lobulated mass rolls out of its bed or is easily detached, until some corner appears where the nutrient vessels enter. Haemor- rhage is inconsiderable, but when these vessels are divided, a ligature or two may be needed. Any small portion of the tumour left behind is immaterial, it ceases to grow. The portion of skin to be removed is not so extensive as would at first sight appear necessary. Any small portion spoilt by pressure and any superfluous portion, may be included in the excision; but the remaining integument will retract and pucker up, after the operation. r Fibro-cellular Tumour.—This growth is distinguished from polypus mucous or cutaneous, chiefly by its relation to the adjoining texture.' Both are over-growths; but, while polypus is merely an out-growth of hbro-cellukr tissue, the same structure, as a tumour, is distinctly isolated by a capsular investment. J Structural Condition, and Diagnostic Characters.—The mass, thus * Pathologie, B.ii. ,. 189. f Anat. Path. ii. 412. TUMOURS OR MORBID GROWTHS. 93 detached, is roundish, and of tolerably regular outline, usually deeply and largely lobed. Its chief physical character is a remarkably elastic tension, due to the structural resemblance of this tumour to dropsical cellular tissue, circumscribed. It may grow to great size and weight, perhaps forty pounds. Section shoAvs a yellow surface, marked with white lines, which have an undulatory direction across the tumour, and may divide its substance into distinct lobes. The yellow substance, the white bands, and the capsule, alike consist of fibro-cellular tissue, more condensed in the latter portions; but the whole is remarkably succulent, being infiltrated with a serous fluid, which exudes plentifully and continues to ooze from the cut surface. Situation.—Fibro-cellular tumour occurs most frequently in the scro- tum, labium, or tissues by the side of the vagina; or in the deep-seated iuter-muscular spaces in the thigh and arm. As out-growths, some proceed from, and are connected with, the mucous membranes, forming polypi—e.g., in the nasal passages, very rarely in the antrum ; in the external auditory meatus; in the uterus, and urinary bladder. (Paget.) As cutaneous out-groAvths, they appear on the scrotum, prepuce, nymphae, clitoris and its prepuce. In one instance, a fibro-cellular out-growth—Avhich I examined Avith the microscope after its removal from the clitoris—was the size and shape of a large cocoa- nut. It weighed thirty ounces. Fibro-cellular tumour, not out-growth, is usually solitary. Origin.—This kind of growth may begin at any period of life, but most rarely before adult age, and most frequently at middle age or later in life. It is so seldom referable to inheritance, any general disease or to violence, that any such relation would appear to be only a coincidence. The tissue of which, together with the serous fluid, this tumour consists, represents an immature state of the normal fibro-cellular tissue. With many Avell-developed filaments, there are more abundant nuclei and cells, forming fibres—fibro-cellular tissue, in various stages of de- velopment. Yellow elastic tissue is very rarely present, unlike its frequency in ordinary connective tissue. Analogous, as the texture of this tumour is to ordinary fibro-cellular tissue; it is, nevertheless, of rare occurrence, compared Avith other tumours—fatty, or cartilaginous __whose component textures, respectively, are reproduced far less fre- quently than this tissue. Course.__Portions of cartilage sometimes partially ossified, are occa- sionally produced in, or over, the tumour. (Paget.) Its texture may also degenerate. The rate of growth is variable ; being very rapid, as much as three or four pounds a year—e.g., in the scrotum ; or more slowly in- creasing. Recurrence is very improbable, unless the tumour be unusually soft and'succulent, and the fibre-cells in great proportion rudimentary. Treatment.—Excision of a fibro-cellular tumour is the only effectual mode of removal. It becomes necessary owing to the increasing size of the o-rowth. The operation cannot be accomplished with the same facility as that of a fatty tumour. Nevertheless, a thin capsule defines the lobulated mass, its connexions are not very close, and the haemorrhage is but slight compared with the size of the tumour. I have excised such tumSurs without any recurrence. The largest fibro-cellular out-groAvth I have yet seen,—that of the clitoris enlarged to the size of a cocoa-nut, was easily removed by a sweep of the knife through the peduncle. 94 GENERAL PATHOLOGY AND SURGERY. Painful Subcutaneous Tumour, or Tuhercle—so named by Mr. W. Wood * Avho first described it—is a peculiar variety of fibro- cellular tumour, to Avhich and to fibrous tumour, it is structurally allied ; but peculiar, if only as distinguished by the pain, intense and paroxysmal, which commonly occurs, and which is not to be accounted for by the structure of the tumour, itself perhaps destitute of any nerve- filaments, nor by any special relation to adjacent nerves. This painful tumour, situated in the subcutaneous cellular tissue, is barely visible; for it is beneath the skin, and scarcely projects. It is also of small size, rarely exceeding half an inch in diameter; but it can be readily felt, as a roundish body, A-ery firm and elastic. Isolated by a capsule, this hard body is free in the subcutaneous tissue, and is, there- fore, so far moveable ; but it may be intimately adherent to the skin, and move with it when pressed under the finger. The superimposed skin, if adherent, has the general appearance of a cicatrix; it is slightly puckered, stretched, glistening and white, unless during a paroxysm of pain, when it may become congested and swollen, and the surrounding blood-vessels turgid. The surface and section of this tumour are alike in colour Arariable; commonly yelloAvish; sometimes only greyish, or pure white. Its sub- stance consists of fibro-cellular or fibrous tissue, with an abundance of nuclei intermixed; and the whole represents an immature state, or rather various immature states, of either tissue. Nerve-filaments have not been discoArered. The tumour is usually solitary, as well as subcutaneous. It is thus also distinguished from Neuroma, a fibrous tumour connected with a nerve. This latter species of growth is characterized by the presence of nerve-filaments in, or spread over, the mass; and by the large number of such tumours often produced in various parts of the body, not less perhaps than 2000 having been found in one unprecedented case. (R. W. Smith.) Situation.—Painful subcutaneous tumour or tubercle occurs, as its name denotes, beneath the skin; and especially in the extremities, more particularly the lower limbs, very rarely on the trunk or face. It has, I believe, been found deeply imbedded in the substance of muscle. This tumour is solitary in nearly every instance. Origin.—Painful tubercle is very rare in both early life and old age. It occurs much more commonly in the female than in the male. Course.—SIoav growth, and non-recurrence when removed entirely, characterize the life of this little tumour. Treatment.—This variety of fibro-cellular tumour generally requires the same treatment as that groAvth. But excision is resorted to, and with the ready concurrence of the patient, to exterminate, so to speak, the other- Avise excruciating paroxysmal pain in the tumour, rather than in conse- quence of any mechanical inconvenience by its size, which is always inconsiderable. The pain may perhaps be relieved, for a time, by firm pressure with a metallic ring placed on the circumferential portion of skin; but the tumour will ultimately have to be excised to obtain per- manent relief from suffering. I am not aware that pain ever recurs in the cicatrix, although free excision may be advisable, as a precaution; assuredly the tumour itself never returns, when completely extirpated. * Edin. Med. and Surg. Journal, vol. iii., 1812. TUMOURS OR MORBID GROWTHS. 95 Fig. 15.* Neuroma is also amenable only to excision. The nerve-filaments, enclosed in, or expanded over, this little tumour, must generally be divided. Occasionally, the tumour can be dissected out of the nerve, leaving it intact. This more conservative mode of excision is especially important in the case of a large nerve, as the sciatic. But the presence of more than one, sometimes very many, neuromata in various parts of the body, may render any operation useless. As a palliative, in both these forms of painful tumour, the topical ap- plication of the most benumbing anodynes—e.g., the tincture of aconite, is worthy of trial. I have met with instances of fixed pain limited to a spot, at the junction of the ball of the thumb and Avrist, and in other situations; where great relief has been obtained by the occasional application of aco- nitine ointment,—one grain to a drachm of lard. The best aconitine must be used ; it was prepared by Messrs. Morson, of Southampton-row, who are justly celebrated for the preparation of this and other vegetable alkaloids, Fibrous Tumour.— Structural Condition and Diagnostic Characters.— The great firmness and elasticity of this groAvth are peculiar; and less so, its spheroidal shape, when uninfluenced by the pressure of surrounding parts, and its occasionally lobulated character. The tu- mour sometimes attains a large size and weight, even seventy pounds. Its chemical basis is gelatine, but the other constituents are unknown. On section it presents a greyish colour, variously intersected by white opaque lines. It consists of the Avhite, and perhaps the yelloAV or elastic fibres of ordinary fibrous tissue, which have an undulatory arrangement (fig. 15) ; and like that tissue, it is but scantily supplied with blood-vessels, which pass into the substance of the tumour from a fibro-cellular capsule, this invest- ment being more apparent around those tumours which are imbedded in solid organs. Situation.—Fibrous tumours are formed in connexion with the fibrous or fibro-cellular textures; most commonly in the substance of the uterus, or in the fibro-muscular tissue of the ligamentous reflexions of the pe- ritoneum ; in the ovaries, Fallopian tubes, or vagina ; (Walshe) ; in the interstitial fibro-cellular tissue of nerves. Connected sometimes with bone, and—like cartilaginous tumours—formed either in its substance, or betAveen it and the peritoneum. The jaAvs are most liable to this kind of growth. Connected Avith the dura mater, is another frequent situation. In the sub-mucous cellular tissue, "more particularly of the intestine, stomach, and oesophagus; now and then in that of the larynx;" (Roki- tansky) ; in that of the pharynx, the nares, the frontal and sphenoidal sinuses • in the sub-peritoneal and sub-pleural tissue ; (Walshe) ; in the subcutaneous cellular tissue, as in the lobules of ears, after piercing for ear-rings (Paget) ; in the mammae, testicle, thyroid gland, thymus gland; in the arterial tissue; and indeed Avherever fibrous or fibro-cellular tissue is normally present or most prevalent. * Uterine fibrous tumour, section, like polypus, but discontinuous with the sub- stance of the uterus. (Paget.) 96 GENERAL PATHOLOGY AND SURGERY. Fibrous tumour is usually a solitary growth ; excepting in the nerves or uterus, in either of which several may co-exist. But when in the uterus, this species of growth rarely forms in any other part at the same time. (Paget.) Origin.—This tumour has perhaps no definite relation to any period of life, nor to any hereditary constitutional tendency. An apparent ex- ception to this negation, is the uterine fibrous tumour; a fibro-muscular rather than fibrous growth, and which may have some physiological relation to the organ in connexion with which it occurs. Course.—The influence of fibrous tumour is purely local and me- chanical. The rate of growth is slow, as compared with that of fibro- cellular tumour; but recurrence is equally improbable. Varieties.—Earthy matter or cysts may be found within the substance of this growth, and hence the terms,—fibro-calcareous and fibro-cystic, as designating these modifications. Other and more important varieties are recurring growths;—the fibro-nucleated (Bennett), and the recurring- fibroid. (Paget.) (a) The fibro-nucleated variety presents the external appearance and general characters of an ordinary fibrous tumour, for which it might be readily mistaken. But, the microscopic characters are those of the white fibres of fibrous tissue, mixed with numerous large oval nuclei ; thus representing a developmental condition of healthy fibrous tissue. In point of course and tendency, the fibro-nuoleated variety does not affect the lymphatics around, nor does it contaminate more distant parts; yet, when extirpated, it has a tendency to return, in situ, (b) The recurring fibroid variety also, in its first stage, pre- sents the external appearance and general characters of fibrous tumour. But, in its minute structure it consists essentially of fibre-cells, cells elongated and attenuating into white fibres, mixed with nuclei; thus representing another developmental stage of healthy fibrous tissue. Not affecting parts contiguous or remote, the recurring fibroid Arariety has emphatically, as its name would suggest, a tendency to return, again and again, in situ. Moreover, in this its second stage, it successively assumes the appearance of encephaloid cancer; having now become soft, bloody, and fungoid; but retaining its former structural characters, and vital significance, which is only somewhat less than that of encephaloid cancer. It will, therefore, be observed that the fibrous tumour, and recurring fibroid in its first stage, possess the same physical characters, conjoined Avith a different structure; and conversely, recurring fibroid tumour, in its first and second stages, presents dissimilar physical characters, associated with the same essential structure. Yet the vital significance of these growths is of Avidely different import; ultimately approaching to that of cancer in its typical form. Growths thus constituted, and endowed, illustrate, even more con- spicuously than the fibro-nucleated variety, the diagnostic insufficiency of Physical Signs, [P. p. 224]; and the superior diagnostic value of minute Structural characters, [P. p. 243]. The practical value of this principle of Diagnosis, is to be estimated by the clinical fact, that, in all available situations, the minute structural characters of the tumours in question—and of other doubtful tumours— may be discovered by puncture with a grooved needle and direct exa- mination of the tumour-substance with the microscope. TUMOURS OR MORBID GROWTHS. 97 Origin.—Both the recurring varieties of fibrous tumours, usually begin between youth and middle age, very rarely either in childhood or in advanced life. Treatment. Fibrosis tumour.—Excluding this form of growth in the uterus—excision is still the only knoAvn remedy. Considering the large size to Avhich the tumour sometimes attains, and especially, the irregular shape Avhich it acquires by adaptation to the parts around; the operation should be performed early. It is, however, accomplished less readily than that for a fatty, or even a fibro-cellular, tumour. Y/et a thin capsule defines, and but loosely attaches the tumour to surrounding parts, from Avhich it can be easily split; and the haemorrhage is incon- siderable, as pertaining to the tumour. In connexion with bone, the attachment is very close, and the basic portion of bone will probably have to be removed. Enucleation—or simply turning the tumour out of its bed—is available in some instances; chiefly for the removal of uterine fibrous tumours. Recurrence, after either mode of operation is very improbable. Recurring Fibroid, and Fibro-nucleated Tumours.—The treatment of both these recurring varieties of fibrous tumour is governed by the same general considerations. They are not influenced by any known medicinal agents, except perhaps the first named variety of this groAvth. Iodide of potassium in large doses continued for several Aveeks, seems to have prevented the return of recurring fibroid tumour, in cases observed by Dr. Esmarch of Kiel. Excision is the only other resource. The size and often rapid growth of these tumours, are urgent considerations. The operation must be freely performed, to ensure, if possible, total extirpa- tion of the tumour, which, hoAvever, is localized, though apt to return. Haemorrhage may be profuse. The probability of recurrence is uncertain. Any such tumour may be removed, apparently entirely, an indefinite number of times, and each interval may be of longer duration, even to some years apart, after repeated operations; thus prolonging life, and granting successive periods of ease. Or, as is usually the case, this history may be reversed ; more rapid groAvth, and shorter intervals of freedom, larger operations, pro- gressive exhaustion and death. Cartilaginous Tumour.—Enchonpp.oma of Muller.—Structural con- dition and Diagnostic characters.—-This tumour presents the appearance, the chemical composition, and the struc- Fig lf_ ture of masses of foetal cartilage. It is enclosedin a toughfibrous capsule,Avhich conducts a feAv blood-vessels. The surface of a cartilaginous tumour is more or less irregular and lobulated, the fibrous capsule passing in between and separating the lobes ; the whole mass varying also considerably in size (Figs. lfi, 17). Its substance is pulpy or more consistent it may be hard, but elastic, crisp when cut, and a section is bluish-Avhite, like London milk, glistening • Enchondroma of the hand (Druitt.) The tumours are dawn tco regularly round, and have not the nodulated character of the cartilagmous tumour. (F. J. G.) 98 GENERAL PATHOLOGY AND SURGERY. and translucent. These appearances, hoAvever, vary with modifications of structure. Fig. 17. Situation.—Cartilaginous tumour is most frequently connected with the bones and joints; especially those of the hand—i.e., phalanges and meta- carpus, the corresponding bones of the foot, particularly the last phalanx of the great toe ; the lower end of the femur, neighbouring end of the tibia; the humerus, sternum, ribs, ilium, and cranium. Apart from bone and cartilage, these growths may form in the parotid gland, testicle, mammary gland, lungs, and in the subcutaneous areolar tissue. (Rokitansky.) * Cells, and inter-cellular substance or stroma, of a cartilaginous tumour, from the phalanx of a finger. Many of the cells are only drawn in outline ; some of them pre- sent double or triple contour lines ; most of the nuclei are large and granular The groups of cells are intersected by bands of tough fibrous tissue. Magnified about 400 times. (Paget.) TUMOURS OR MORBID GROWTHS. 99 This kind of groAvth is not unfrequently solitary, excepting in con- nexion With the bones of the hands or feet, Avhere several may co-exist. Origin.—In connexion Avith bone, cartilaginous tumour begins most commonly at an early period of life; some, on the hands, in infancy, others, more often, betAveen childhood and puberty. Their beginning in later life is, however, not very rare, even on the bones; and in other parts, they commence, usually, in full adult or middle age. Inheritance, or injury, may have some influence in the production of this tumour, particularly in connexion with bone. Course.—The influence of a cartilaginous tumour is purely local and mechanical. The rate of groAvth is uncertain; generally sIoav, occasionally rapid. Recurrence is very improbable, unless in the case of a soft cartilaginous tumour. Varieties.—The consistence of an ordinary cartilaginous tumour is liable to undergo remarkable changes. A species of ossification some- times takes place, beginning either on the surface or within the substance of the tumour. Again, the Avhole tumour may soften and feel like a fatty groAvth, or a mass of colloid cancer; or ossific nodules may soften and feel like a group of cysts. Such are the most important points of apparent resemblance betAveen the cartilaginous tumour and other growths. Myeloid tumour is allied to the fibrous by virtue of one structural element, the fibre-cell, and to the ordinary cartilaginous tumour by its more abundant many-nucleated corpuscles. These corpuscles and imper- fect fibres appear to be identical with those of healthy rudimentary bone. Hence, the marrow-like "myeloid" in substance, as so designated by Paget, has also been named " fibro-plastic" tumour, by Lehert, its struc- tural elements resembling those of granulations springing from healthy bone. The external characters of the myeloid Arariety of cartilaginous tumour are tolerably definite. Its surface is more or less lobulated. If enclosed within bone, its shape is uniform and spheroidal if seated on the surface of a bone, its outline is irregular, as seen in epulis. The fleshy, inelastic firmness of a myeloid growth is remarkable, although its consistence varies. On section, the surface presents a greyish-white basis colour, daubed with irregular blotches of a bright red, livid or broAvnish tint. This blotched appearance is unconnected Avith any cor- responding vascularity, the supply of blood-vessels being scanty even Avhen the tumour is most ruddy. The cut surface is also succulent, and exudes a yellowish fluid. Situation.—Myeloid tumour selects bone more frequently than any other tissue. Paget has seen this groAvth in the mammary gland, and probably also in the neck near the thyroid gland. Origin.—The tumour begins very rarely in early life, or in old age; most frequently betAveen youth and middle age. It is seldom referable to inheritance, defective health, or injury. Course.—The rate of groAvth is usually slow. Myeloid tumour is not apt to ulcerate or protrude like a recurrent fibroid groAvth ; but it is liable, if not prone, to return Avhen extirpated by the knife, thus differing essentially in its vital career from the typical form of cartilaginous tumour. Treatment.—Cartilaginous tumour must be removed by surgical opera- tion But the size to Avhich it may grow is scarcely so much a considera- H 2 100 GENERAL PATHOLOGY AND SUKOERY. tion, as the firm attachment of the tumour to bone, in the great majority of cases. Amputation, therefore, rather than excision is indicated. The performance of the latter operation is aided by certain circumstances. The mass, usually lobulated, is defined by a tough capsule investing the whole surface, excepting at the base of attachment. Within bone, this investment is complete. In either case, the capsule is connected to the texture around, by a dry connective tissue which can be more or less readily split up. The haemorrhage is but slight, as occasioned by removal of the tumour itself only sparingly vascular ; and the surrounding textures are singularly healthy. Enucleation of a cartilaginous tumour from within bone, is—observes Mr. Paget—more often practicable than practised. Recurrence need not be apprehended, otherwise than in exceptional cases. Myeloid tumour admits only of free excision or amputation, and as a recurring growth is far less favourable for operation. Vascular or Erectile Tumour.— Structural Condition, and Diagnostic Characters.—This tumour essentially consists of a conglomeration of blood- vessels, connected together, more or less intimately, by fibro-cellular or connective tissue, which may form an investing capsule; the Avhole being thus circumscribed as a distinct tu- mour, but of irregular shape, and perhaps lobed (Fig. 19) ; or, the mass not being distinctly isolated, is dif- fused, flattened, and shades off into the surrounding textures. The size or extent of such a mass, in either case, varies with its groAvth, and is subject to temporary alterations, under circumstances which will be noticed presently. Situation.—This species of tumour may be deep-seated, in or among muscles, in bone, the stomach, spleen, liver, the orbit, the tongue, and indeed wherever capillary blood-vessels naturally exist and most abound. The diffused form is more frequently situated superficially, as beneath the skin, and probably involving it; constituting the common cutaneous naevus, as seen on the scalp or the face. Varieties.—Three varieties of this tumour are well defined, and easily recognised when it is patent. The constituent blood-vessels are capil- laries, with arterial and venous trunks proceeding respectively, to and from the mass; but either order of Aressels may predominate, and con- stitute nearly the whole mass, apart from the connective tissue. Thus then there are the capillary, the venous, and the arterial Ararieties of vas- cular tumour. The first consists almost entirely of capillaries—large, dilated, and convoluted. The second, almost entirely of veins or venous sinuses— * Section of an erectile-tumour—showing the fibrous trabecular structure, and in- vesting capsule.—Museum of the Royal College of Surgeons, England. Drawn one- third larger than the specimen. TUMOURS OR MORBID GROWTHS. 101 forming a cavernous and erectile structure. This variety of vascular tumour, Avas that which John Bell specially described,* and to which he gave the name of " aneurism by anastomosis," or " Aneurism by the dilatation of anastomosing vessels, f He compared it to the erectile struc- ture of the penis, the gills of a turkey-cock, or the substance of the spleen, placenta, or Avomb. The third variety consists almost entirely of arteries—large, tortuous, and perhaps convoluted. This is now called— " aneurism by anastomosis." (Fig. 20.) These varieties of structural condition ure accompanied with corresponding peculiarities of physical characters, by which their diagnosis during life can be determined. Fig. 20. The vascular tumour is soft and compressible, but regains its former size when the congeries of vessels is left free to fill again. Its substance someAvhat resembles a sponge ; and if visible, as Avhen subcutaneous or in the skin, the colour of this distended sponge plainly shows that it is full of blood, arterial or venous. The capillary and venous varieties are alike characterized by their circumscribed shape and soft doughy consis- tence which can be moulded under the fingers; but at the same time a trembling sensation or indistinct throbbing is felt, if the mass for the most part be venous, and have attained some size. After compression, the tumour slowly re-distends, and assumes increasing size and tension during exertion, especially if sudden and violent, as running, coughing, straining, struo-Tling; and by any obstruction to the free return of venous blood. A bluish tint is perceptible when the tumour is situated superficially. Lastly if Avounded, the mass collapses. The arterial variety is chiefly dis- tinguished by its strong pulsations, and threatening distension, increasing * Principles of Surgery. Ed. by C. Bell, 1826, vol. hi. p. 328. t Ibid., p. 386. 102 GENERAL PATHOLOGY AND SURGERY. also under any occasional excitement of the heart's action, and Avith the floAV of arterial blood. Origin.—The vascular tumour is not unfrequently a congenital growth; it may be a subsequent formation, but more frequently in childhood than in after years. The progress of growth is not generally steady, but by fits and starts; sometimes rapid, sometimes slow-growing. Very commonly—observes Paget—their increase is only proportionate to that of the rest of the body; and when full growth is attained, they also cease to grow. Not rarely they are stationary, or shrink, even while the rest of the body is growing ; and this is especially likely to happen with those that are white and scar-like Avhere the skin is involved.* Course.—The same authority also notices certain structural altera- tions to which the vascular tumour is subject, by degeneration or by disease. These morbid conditions disguise the original character of the tumour, and may now mislead the diagnosis. Thus, a vascular tumour may be- come converted " into a soft, but tough and dry yellow-ochre or brown substance, like that of a supra-renal capsule." Scar-like patches is another transformation, affecting the substance, or surface of the tumour, and accompanied with closure of the vessels in that portion, Acute in- flammation may consolidate and cure; or, leading to ulceration, form bleeding sores, ill-disposed to heal. Either blood-clots, or phleboliths, sometimes partially consolidate; or cysts, serous or sanguineous give a more elastic feel to the mass. More rarely, this kind of growth, forms in another growth, and usurping its structure, converts part, or the whole of such growth into a vascular tumour, and acquires its character. Lastly, "it is probable also that one form of vascular tumour may be converted into another: a capillary one becoming either arterial or venous, by the excessive growth of one or other set of vessels ; or an arterial one, by opposite changes, becoming either capillary or venous." Treatment.—Vascular or Erectile tumours admit of treatment in ac- cordance with each of the three general indications pertaining to morbid growths. (1.) Absorption, by compression, steadily maintained by means of the air-cushion and spring. Compression is most practicable and effectual when the tumour rests on bone, thus supplying counter-pressure. (2.) Obliteration, by cauterization, or injections, for the purpose of producing sloughing or consolidation of the tumour. Either plan of treatment is most appropriate for small vascular tumours, as certain naevi. In parts where the deformity occasioned by sloughing and cicatri- zation are unimportant considerations; cauterization, with the strong nitric acid freely applied to the integument covering the tumour is perhaps war- rantable. In parts otherwise circumstanced, as the face, the injection of some stimulant into the tumour is preferable, with the view of exciting inflammation short of sloughing, and thence consolidation of the tumour. Perch loride of iron may thus prove remedial, introduced drop by drop at different points, by means of a glass syringe, having a screw piston and a fine penetrating nozzle. Setons of silk, passed through various parts of the tumour, and allowed to remain in for some days, will, perhaps, more sloAvly produce the same result. I have not had much experience in either of these, or similar modes * A System of Surgery, 1860. Ed. by T. Holmes, vol. i.; Tumours. TUMOURS OR MORBID GROWTHS. 103 of treatment. What I have done or seen has led me to avoid such appli- cations, as useless or perilous. (3.) Removal, by ligature or excision. The former method is ap- propriate for vascular tumours larger, and, therefore, more arterial or venous, than those which can be safely obliterated by caustics or injec- tions, or in cases where such treatment has failed. The advantages are ; less liability to haemorrhage, and a more healthy sore when the tumour is detached. The difficulties are; to include all the vessels connected Avith the tumour around its base, and to completely strangle without cut- ting them by the ligature,—thus ensuring extirpation of the growth. But success is at least equally uncertain with regard to the treatment both by obliteration and absorption. Cessation of pulsation, a thrilling tremor in the tumour, and inability to reduce it by pressure; are signs that the operation of ligature has been effectually performed. An erectile tumour requires, and is amenable to operative treatment, according to its size, situation, and the character of the growth. Nffivus.—When of small size, cutaneous, and not progressively in- creasing, a naevus may well be left to itself; and it may atrophy, wither, and disappear. When of large extent, although superficial, as occa- sionally seen on the face, presenting the appearance of a large purple patch; such naevus must be left alone, it is irremovable, albeit a great disfigurement. But, when naevus is of large size, or subcutaneous, and increasing in size, occasioning also much disfigurement; operative inter- ference becomes n'ecessary, and indeed urgent in proportion to the de- velopment of these characters. Operations for the cure of naevi may be performed with a view either to their destruction and obliteration, or to their removal. (1) To induce adhesive inflammation in the substance of the tumour, with coagulation and permanent plugging of the erectile tissue; (2) cauterization, by the application of strong nitric acid or potassa fusa, in order to thus destroy the groAvth; (3) removal by excision, with the knife ; or (4) by ligature, applied subcutaneously. Adhesive inflammation, as a means of destroying naevus, is eligible only when the tumour is of small size, and occurs in situations inaccessible for excision or ligature. Naevi situated near the eyelids, at the inner canthus, or on the tip of the nose, are thus circum- stanced. Inflammatory adhesion and coagulation may be induced in various Avays. By the injection of some stimulant, as perchloride of iron, by means of a screAV-piston glass syringe, as used for the hypodermic in- jection of morphia; care being taken to throw in not more than two or three drops at one time, lest sloughing supervene, or coagulation extend- ing into the surrounding vessels, a fatal embolism ensue from a clot entering the general circulation. Galvano-puncture is another mode of exciting coagulation, and consolidation. Subcutaneous puncture, and division of the vascular tissue, by means of a fine tenotomy knife, is also an efficient, and a safe mode of destroying the tumour, in like manner. Or by the introduction of seton-threads, for a sufficient time, and at dif- ferent parts, so as to induce inflammatory consolidation. Cauterization, is eligible for the destruction of naevus, where it is small, and cutaneous; and its disfigurement is worse than the cicatricial scar resultino- from the application of strong nitric acid or potassa fusa. Thus, a small "'mother's mark," or an acquired vascular spot, may be touched Avith a glass rod dipped in the acid, or lightly pointed with a stick of the caustic. 104 GENERAL PATHOLOGY AND SURGERY. Excision may be resorted to for the removal of large naevus, but this method will be appropriate especially when the growth is distinctly en- capsuled, and can be dissected or shelled out. Ligature, applied subcutaneously, is the other method of removal which must be had recourse to, in all other conditions of naevus, when of large size, not encapsuled, but connected with large feeding blood- vessels, especially arterial. The haemorrhage attendant on excision would be dangerous or fatal, and can only be prevented or controlled by ligature. Accordingly, the objects to be accomplished are; the complete and immediate strangulation of the vascular tissue, observing to include the Avhole tumour, and well around the limits of the disease ; but avoiding the skin, which may either be divided in the intervals of the ligatures, or a single ligature be passed subcutaneously. Small, firm, round whip- cord answers best. The naevus needles are curved, and firmly set in Avooden handles, resembling aneurism-needles. Naevus, of moderate size, and in a situation where cicatricial disfigure- ment is not of much consequence, may be ligatured by tAvo double ligatures passed underneath the base of the tumour, and crossing in opposite diameters, so as to divide it into four sections; the skin may be either reflected, or divided circumferentially, in the intervals of the Fig. 21. ligatures, which are then successively drawn sufficiently tight around viS*!! °f tumour' and tied in a reef-knot. An ordinary naevus on a child s head, generally thus admits of ligature. (Fig. 21.) The tumour when effectually strangled, sloughs in a few days, leaving an open sore which granulates and cicatrizes. Naevus of larger size, and so placed that the sacrifice of integument TUMOURS OR MORBID GROWTHS. 105 would entail much disfigurement, may admit of subcutaneous ligature; the skin being left entire in this operative procedure, and consequently not sacrificed by sloughing. The naevus-needle, armed with a double ligature, is introduced at some point of the base of the tumour, and carried round its circumference to the same point; the cord is drawn out into a single ligature, the needle withdrawn, and the two ends pulled steadily and tied tight enough to thoroughly strangle the included mass of vascular tissue. If the mass be so large, or so placed, that it cannot be thus encompassed by a single passage of the ligature, then, the needle- point may be made to emerge at a convenient spot, one end of the cord drawn out, the needle withdraAvn, and having been re-threaded with that end of the ligature, it is re-introduced at the point of emergence and carried round the remainder of the tumour to the point, Avhere it was first introduced; the operation being completed by strangulation and securing the ligature. A naevus on the cheek can be removed by this method, without any resulting disfigurement, more than a puckered appearance. I have known a dragging down of the lower eyelid to ensue, but this can be remedied by the operation for Ectropium. Ligature may be employed at an early period of life ; in infants a month or two old, and with a successful result. Aneurism by Anastomosis, consists of large freely communicating blood-vessels, principally arterial; and the tumour must be removed by ligature, either of the circumferential feeding branches, or of the main trunk of the part. The former procedure has not been followed by successful results; ten recorded cases having failed, Avithout one single instance of ultimate cure. In two cases, however, where the scalp was the seat of aneurism by anastomosis, Gibson aided the effect of circumferential ligatures by incisions around the tumour in the intervening spaces; and this procedure proved successful. Ligature of the main trunk has been practised on the carotid, when the tumour was seated on the scalp, or in the orbit; or the brachial, and femoral arteries, have been ligatured, when the disease occurred on the arm or leg. The carotid has been tied in twenty-three recorded cases; in five of which, both arteries were tied at intervals of several weeks. Single ligature proved successful in some of the cases; double ligature in all five. Ligature of the carotid for aneurism by anastomosis in the orbit, has been performed in thirteen cases; Avith a successful result in the majority. These tAvo procedures,—ligature of the circumferential arteries, and of the main trunk, may be combined or practised in succession, and the former aided by the intervening incisions. Excision is also applicable to the larger sized vascular tumours; especially those of a venous character, and those which are encysted. But the situations should be such as to allow of the parts being readily brought together, after the operation. Free excision, moreover, is necessary to prevent the risk of haemorrhage subsequently, and com- pression of the coapted parts Avill be an additional precaution. Ossi.ous and Glandular Tumours, respectively, are more properly considered in connexion Avith Diseases of the Bones, and Glandular Organs. Infiltrating Growths comprise, perhaps, only one genus—Lancer : its typical species being Encephaloid, Scirrhus, and, perhaps, Colloid, with 106 GENERAL PATHOLOGY AND SURGERY. Fig. 22.* Fig. 23. f many sub-varieties ; distinguished chiefly by shades of difference in their general characters of colour, consistence, shape, size, and mobility. Structural Condition, and Diagnostic Characters.—The three species of cancer present under the microscope the same cell. (Fig. 22.) This, at first colourless and pellucid, consists of a delicate envelope, containing a large clear nucleus or two, sometimes more, never less —Avithin each of which is imbedded one or two nucleoli, also large and clear. Such is the " cancer cell." (Bennett). But is this cell peculiar to, and characteristic of cancer ? In considering the diagnosis of cancer, I shall have occasion to recur to this question. The cell assumes various shapes; either round, more usually caudate or spindle-shaped; and presents other forms by outgrowths in one or more directions. These cells are deposited in a filamentous stroma or meshwork, which has a variable locular arrangement and closeness of texture. (Fig. 23.) This inter-cellular stroma is probably, in most cases, nothing more than the fibrous tissue of the textures, amid which the cancer-cells are infiltrated. But another inter- cellular substance—gelatinous, translucent, and amber-coloured, may be present in more or less abundance, and this is probably peculiar to cancer,—the colloid species. The leading species of cancer are further allied by possessing a similar chemical basis : namely, chiefly albumen, associated with fibrine, gelatin, osmazome, fat, certain salts,—such as the phosphates and carbonates of lime, with the carbonates of soda and magnesia, the oxide of* iron, and water. But the results of chemical analysis hitherto made are not very reliable. Species.—As the proportion of cells, or of inter-cellular matter, pre- vails, so do we recognise Encephaloid, or cancer, par excellence, abounding with cells; and, therefore soft, opaque, and of a dead white or faAvn colour. Hence the terms cerebriform or medullary, applied to this form of the disease; and—the cellular or special element of cancer, pre- dominating—encephaloid yields on pressure an abundant quantity of " cancer-juice," which resembles milk or cream. Scirrhus, on the other hand, is far more fibrous, and, therefore, hard and craggy; semi-trans- parent in a thin section, and of a bluish-white or fawn colour; compara- tively little " cancer-juice "is exuded on pressing the cut surface of the fibrous stroma, and this little rather resembles thick gruel than cream, or it may be a small quantity of thin yellow serous fluid exudes; but the fibrous stroma itself contracts, whereby the cut surface speedily assumes a concave aspect, unlike the section of any other tumour, which remains level or becomes slightly convex at its margins. Colloid—in contrast with both the foregoing—is gelatinous, owing to Cancer-cells a, from scirrhus of the mamma. Transparent cells b, seen after t Section showing the arrangement of cells and fibrous stroma in scirrhus of the mamma. (Bennett.) TUMOURS OR MORBID GROWTHS. 107 the predominance of the gelatinous, intercellular matter, and in Avhich the cells are suspended; the Avhole being infiltrated through a delicate fibrous stroma : it appears, therefore, either as a trembling mass, or a glairy fluid—dimly transparent, and of a greenish yellow colour. Cancer is essentially an infiltrating groAvth; but while this peculiarity almost constantly prevails in scirrhous and colloid cancers, encephaloid becomes encysted, about as frequently as it remains free. A very thin, yet distinct fibro-cellular capsule may invest this typical form of cancer, and from which thin partitions pass into the tumour thus defined, inter- secting its substance, or investing its several lobes. Generally speaking, this capsule is not adherent to the surrounding textures; it furnishes a matrix in which numerous and tortuous blood-vessels ramify, previous to supplying the mass'itself with vessels. Encephaloid is, indeed, always abundantly vascular, as compared with scirrhous and colloid, both of Avhich are relatively destitute of blood-vessels. Nerves probable exist in the substance of a cancerous tumour; for pain is felt in scirrhus, and less so in encephaloid cancer, when cut into during a surgical operation. But the question of nerve supply, in point of proportion and distribution, has yet to be demonstrated anatomically, by dissection. Tumour.—The investing capsule, Avhen present, gives a definite outline to an encephaloid tumour—round, oval, spheroidal, or lobed, which con- trasts Avith the irregular and unbounded .outline of scirrhous and colloid, the infiltrating course of Avhich is very rarely circumscribed. The boun- dary of either of these species of cancer is perceived rather by their degrees of consistence as compared with that of the textures around the seat of infiltration. The greater vascularity of encephaloid, coupled with its capsular and there- fore more isolated condi- tion, in many cases, are cir- cumstances favourable to a corresponding rapidity of sn-owth, and evolution as a distinct tumour; conse- quently this, the typical species of cancer, fre- quently att.dns an enor- mous size and protrudes (Fig. 24): but scirrhous being differently circum- stanced in these respects remains smaller, rarely ac- quiring a larger size than an orange, and this ren- dered indistinct by infil- tration of the surrounding textures. It shrinks yet smaller by their condensa- tion and absorption, as its abundant fibrous stroma, * Advanced carcinoma of the mamma,—exhibiting bleeding mass. (Cruvoilhiur.) Fig. 24.* a prominent, fungoid, and IDS GENERAL PATHOLOGY AND SURGERY. continuous with parts around, draws texture after texture within the claws, as it were, of the infiltrating mass. (Fig. 25.) Infiltration penetrates omvards, while contraction pulls backward; so that there is a double action at work—like the pull- ing on of a glove. Colloid cancer, although ill provided Avith blood- vessels for rapid growth, is scarcely restrained by a contracting fibrous stroma, and—in this particular re- sembling encephaloid—it spreads to an indefinite size, but not as a distinct tumour. The circumscribed, or non-circumscribed, condition of cancer, much affects its mobility as a distinct tumour. Encephaloid is often distinctly moveable in the organ or textures in which it is embedded; while scir- rhus and colloid can be moved about, only as a diffused, mass in con- nexion with those textures to which the cancer has contracted adhesion by infiltration. Such are the chief peculiarities respecting the shape, size, and mobility of the three typical species of cancer—in addition to their individual properties of consistence (and colour) ; and by the concurrence of which characters they can be readily recognised during life. Diagnosis.—No sufficiently exact structural differences have as yet been detected, by Avhich to distinguish these species of cancer-growth ; we are, therefore, compelled at present to rely solely on their physical characters to determine the question of their (differential) diagnosis, so far as these characters can be recognised through superimposed integuments. This conclusion refers only to the comparative value of structural characters; for many other circumstances associated with cancer—its seat, character of the pain, course, and duration, its influence on sur- rounding parts, the constitutional symptom of cachexia, and the peculiari- ties of age, sex, previous diseases of the individual, and hereditary taint —combine to regulate the diagnosis. But the structural individuality of cancer-growth, as a distinct species of growth, is itself uncertain. The supposed characteristic " cancer-cell," is occasionally absent in tumours, otherwise cancerous ; and similar cells may be found, and as often—according to Forster—in healthy as in diseased tissues, and are, therefore, not peculiar to cancer. These two proposi- tions, taken together, apparently negative the value of the " cancer-cell," as the most exact ground of identification. If, however, structural characters only, are reliable for the exact diagnosis of certain growths—e.q., fibrous tumour, and its recurring fibroid and fibro-nucleated varieties; while in respect to other species of growth—e.g., cancer, the structural individuality of the cancer-cell is equivocal; then, the identification of the latter growth—by virtue of its structural characters—turns upon the question, can the variable condi- tions of this cell be explained ? In tracing the Law of Structural Retrogression, with regard to the interpretation of the minute structural constitution of growths and other morbid products of nutrition (P. p. 93), it will be seen that the structural element of cancer,—the "cancer-cell," corresponds to the cartilage-cell, * Scirrhus of Breast.—Section showing retraction of nipple. TUMOURS OR MORBID GROWTHS. 109 or to certain epidermic cells,—in various rudimentary stages of their de- velopment. Thus may, perhaps, be explained the not unfrequent asso- ciation of cancer-cells with the healthy tissues whose structural elements are analogous or identical. Excluding, therefore, those exceptional forms of growth which simulate cancer in their clinical history, but which do riot present the cells of cancer; and excluding also those exceptionally healthy tissues with which similar cells are found ; this structural element is the most unequivocal sign of the presence of cancer. In like manner, the different species—encephaloid, scirrhous, and colloid—so far as they can be distinguished by structural characters—represent rudimentary stages of analogous cartilage-cells. With reference to the structural individuality of cancer, as a distinct species of growth, and its three leading species or varieties—the value of structural characters is thus fully confirmed, as the earliest and most exact ground of diagnosis. In not a few cases, I have thus clearly demonstrated the nature of a cancer-tumour; by puncture with a grooved needle and submitting the material withdrawn to microscopic examination. The three species—encephaloid, scirrhous, and colloid—may possibly coexist and be combined in the same growth. Of this association I once saw a remarkable example in the post mortem examination of a patient, who had been under the care of one of my colleagues at the Royal Free Hospital. The abdominal viscera were literally agglomerated into an enormous mass of cancer, which consisted of the three cardinal species above mentioned. A beautiful wax model is preserved in the museum of the hospital. Then, again, these species of cancer may succeed each other, as well as coexist, in the same individual. Yet, with all this fraterniza- tion, they never lose their individuality ; they never become transformed. On the contrary, each species preserves its own general characters, and this too, through many subordinate varieties. These varieties, like the typical forms themselves, are, in most instances, occasioned by different pro- portionate quantities of their constituent elements—the cancer-cells and fibrous stroma. Some of them, however, are occasioned by morbid changes of structure; degeneration, and the consequences of inflammation. Varieties.—Many varieties of cancer have been described ; of which some are Avorthy of notice, not because they possess any essential importance, but OAving to the characteristic appearances they present. The most important varieties are the following:—They are distinguished and recognised by their physical characters, Avhich have suggested ap- propriate names. The varieties of Encephaloid are,—" mastoid " cancer, so named from its resembling, on section, the boiled udder of the cow. This term was originally proposed by Abernethy. " Solanoid " cancer resembles, on section, a sliced raAV potato. It is hard, almost homo- geneous, pale yellow, and crisp; hence this name, Avhich was first sug- gested by Recamier. The substance of such a mass yields milk-like fluid in abundance, under pressure, and eventually softens. The "milt- like" tumour, so named from its general resemblance to the milt of certain fishes. (Monro Tertius.) "Nephroid" cancer exhibits, on section, a peculiar arrangement of the fibrous stroma, and a semi-transparent watery glossiness, with other characters, not unlike those which the sec- tion of a kidney presents ; Avhence its name. (Recamier.) " Fasciculate" cancer is another variety suggested by the peculiar appearance of its fibrous structure. (Miiller.) The coexistence of softness, and linear or fibrillar arrangement, constitutes its most readily ascertainable peculiarity. 110 GENERAL PATHOLOGY AND SURGERY. (Walshe). " Haematoid" cancer is a variety of encephaloid, in which the brain-like character is associated Avith an unusual amount of vascularity, the vessels sometimes interlacing so as to constitute a dense and some- what spongy netAvork, without, however, the peculiar structure of erectile tissue. " Fungus haematodes" is rather an advanced stage of encephaloid, than a variety of this species of cancer. It represents the occurrence of interstitial haemorrhage, which either infiltrates the whole mass, or forms irregular accumulations of blood in its substance ; and ulceration of the integuments taking place, a fungoid bleeding groAvth protrudes. "Vil- lous" cancer is a term somewhat expressing the appearance presented by this variety of encephaloid. It is very vascular, and apt to bleed copiously. This and its other characters are well marked Avhen the disease occurs on the mucous membrane of the urinary bladder. It is described by Rokitansky as " dendritic vegetation ;" an excrescence con- sisting, in its stem, of a fibroid membranous structure, on which the branches and villous flocculi are borne, as larger and smaller pouch-like and flask-shaped buddings, or sproutings of a structureless holloAv tissue. " Melanotic," or melanoid cancer, is, with very rare exceptions, medul- lary cancer modified by the presence of black pigment in its elemental structures. (Paget.) This is a species of degeneration, besides which, encephaloid is subject to fatty and calcareous degenerations. Other morbid changes are suppuration and sloughing, which it is very liable to undergo. The varieties of Scirrhus are:—So-called " Chondroid" cancer, Avhich is an early stage of scirrhus, dense and crisp; exhibiting, on section, an unusually shining aspect, and bluish-white colour. (Recamier.) " Lar- daceous" cancer is occasioned by the infiltration of scirrhus through the substance of an organ, which then frequently appears not unlike the boiled rind of bacon. " Napiform" cancer is so named from the peculiar arrangement of its fibrous stroma, which, on section, has some similarity to a cut turnip. (Recamier.) " Apinoid" cancer derives its name from the striking resemblance presented, on section, to the cut surface of an unripe pear. This similitude arises from the dissemination of compara- tively opaque and almost buff-coloured spots through a translucent ground of very pale yellowish-lilac tint. The quantity of more opaque substance gradually increases, and eventually predominates, so as to alter the appearance of the surface completely. (Walshe.) Allied, is the " reticular" cancer of Miiller. " Haematoid" scirrhus is a condition of rare occurrence; but when it does happen, its peculiarities are of the same kind as those of the haematoid variety of encephaloid ; differing, only in being less fully developed. (Walshe.) " Osteoid" cancer, or ossifying fungus growth (Miiller), occurs as a tumour, consisting chiefly of bone, but having on its surface, and" in the interstices of its osseous parts, an unossified fibrous constituent, as firm as fibrous cartilage; after a time, similar growths ensue in parts distant from the seat of the first- formed, and not on bones alone, but also in the cellular tissue, serous membranes, the lungs, lymphatics, etc. It Avould appear to be the cal- careous or osseous degeneration of scirrhous, or of medullary cancer, Avith which it not unfrequently coexists. Uninterrupted gradations may be traced between the osteoid variety and these typical forms of cancer. (Paget.) Scirrhus is subject to other species of degeneration, and to morbid changes in common with encephaloid. Ulceration is more fre- quently observed in the course of scirrhus. TUMOURS OR MORBID GROWTHS. Ill Colloid cancer is singularly exceptional in not presenting varieties, properly so called. Nevertheless, the quantity of fibrous stroma, or of colloid matter, may respectively predominate. If the former, then this species assumes the appearance of a very tough, white, fascia-like mass, in Avhich are small separate cysts or cavities, filled with the colloid sub- stance. In the opposite extreme, large masses of colloid matter appear to be only intersected by fibrous white cords or thin membranes, arranged as in areolar tissue, or in a Avide meshed netAvork. (Paget.) Another variety refers to the quality of the colloid matter, rather than its quantity. It may be, or become, white and pearly, or opaque. I once met with a remarkable specimen of colloid cancer, in a female patient at the Royal Free Hospital (18G2), and which I carefully examined. Most of the abdominal and pelvic viscera were affected with this disease ;—namely, the stomach ; the intestinal canal, which was beset externally, here and there, Avith pedunculated masses of colloid, somewhat resembling plums on their stalks; tAvo colloid masses were imbedded in the spleen; the pancreas was wholly converted into the same gelatinous substance, enclosed in loculi; the bladder was distended with a trembling mass, Avhich rolled out like a jelly, leaving the mucous membrane pulpy, ragged, and bloody. The substance of the uterus and ovaries was infil- trated with drops of colloid, together forming a mass which seemed to be incorporated with a similar condition of the rectum. The gelatinous matter thus extensively diffused, was in some parts white, and of brilliant pearly transparency, looking like colourless and clarified jelly throughout the pancreas; white and opaque in the spleen and uterus; while it pre- sented its usual amber colour and transparency in the other organs I have specified. This opacity of the colloid matter Avas probably due to molecular disintegration. Such are the principal varieties of each of the three typical species of cancer. Some of them are, as I have said, the result of certain morbid changes, to Avhich cancer itself is liable; they are illustrations of a patho- logical law Avhich prevails extensively—that morbid products themselves undergo morbid changes—the diseases of diseases. Hence their almost numberless, and sometimes perplexing, complications. Cyst-formation.—A further illustration of this law, I have yet to notice in relation to cancer. This relation, if not one of accidental association, represents an actual substitution of cyst-formation for cancer- growth, and at the expense of its own structural elements. Thus cysts may either be formed with cancer ; or from and out of the cancer-structure, by their erring development and growth. Mr. Paget's work contains the best summary of this subject, of which the folloAving is an abstract. (I) Respecting cysts accidentally associated Avith cancer, but of inde- pendent formation. Scirrhous of the mammary gland may occupy a portion of it only, in the rest of Avhich many cysts may be formed, that are in no sense can- cerous ; or, the chief lactiferous tubes may be dilated into pouches or cysts, contiguous to, but quite independent of, the neighbouring cancer- o-rowth. Such a cancer may nevertheless in its course enclose these cysts, and they remain for a time imbedded in its substance. The ovary may be the seat of cysts, and also the seat of cancer; the two growths thus accidentally associated, will probably become connected, although of independent origin. Further than this, cancers may groAV from the walls 112 GENERAL PATHOLOGY AND SURGERY. of common cysts—i.e., of cysts which have not originated in cancer- structures. Medullary cancer, especially the villous form, sometimes grows from the walls of cysts which have themselves no cancerous appear- ance. (2) Cysts derived from cancer structures—by their erring development and growth—constitute a series parallel with that of the cysts barren and proliferous, which form in innocent tumours, or in the natural tex- tures. Cancer-cysts having this origin, are, therefore, either barren or proliferous. Of the barren species are :—Cysts filled with serous fluid, variously tinted. Serous cysts are often born in cancers, especially in those of the medullary type, which grow quickly, or to a great size. One or many such cysts may be present on the surface or in the substance of a cancer. Sometimes a single cyst of this kind enlarges so as to surpass the bulk of the cancer, exceedingly perplexing the diagnosis. Sometimes many cysts are present, as if the tumour were entirely composed of them, with can- cerous structure only in their interstices. Sanguineous cysts are born as often as serous, in medullary and other cancers. The imprisoned blood undergoes changes in respect of colour and consistence, thereby diversify- ing considerably the appearances presented by cancers containing these cysts. Colloid cysts, i.e., cysts containing a glairy jelly—not cancerous— may likewise be developed in cancer-growths, by conversion of their structural elements. The proliferous cysts which originate in cancers, bear on their inner surface cancerous growths—thus corresponding with the glandular growths which spring from the interior of cysts in the mammary and thyroid glands. These endogenous groAvths are often found in the alveoli of colloid cancer. Clusters of clavate, or flask-shaped villous processes, resembling those formed in the early stages of " dendritic vege- tation " of villous cancer, spring from the wall of the alveolus. The origin and modes of development of these cysts—simple and pro- liferous—have been traced by Rokitansky, and shoAvn to correspond with those of all other cysts: the only difference being the source of the cyst- formation—here a cancerous element, while in respect of all other cysts it is an element of some natural tissue. Situation.—The preference of Cancer for different tissues and organs, ranges according to the following average scale. (Rokitansky.) " First; the uterus, the female breast, the stomach, the large intes- tine and especially the rectum; next, the lymphatic glands, especially as retro-peritoneal cancer-accumulation in front of the vertebral column ; hepatic, peritoneal, cancer; bone-cancer; cancer of the skin, and of the lips ; of the brain ; of the globe of the eye ; of the testes ; of the ovary; of the kidneys; of the tongue, and the oesophagus; of the salivary glands and parotid;"* to which I may add—Avithout pretending to deter- mine their relative places in the scale of frequency,—cancer of the urinary-bladder, of the pancreas, and of the spleen; in each of which organs I have seen, as already described, masses of colloid. In the re- markable case referred to, other organs were similarly affected; the stomach, intestinal canal, uterus, ovaries, and rectum. This scale does not specify the particular species of cancer, in each of the different tissues and organs named; yet their relative liabilities in this * Pathological Anatomy. Translated. Syd. Soc, 1854, vol. i. TUMOURS OR MORBID GROWTHS. 113 respect is a matter of great practical importance, considering the unequal degrees of " malignancy" evinced by the several species of this growth. (1) Encephaloid-c&ncer—the most malignant species; selects first, in order of frequency, the testicle ; next, the bones and particularly the femur (Paget) ; the intermuscular cellular texture of the limbs; the eyeball or orbit; the breast; the walls of the chest, or abdomen; the lympha- tics. Moreover, encephaloid " occurs in organs in which no other cancer, least of all scirrhous, ever occurs,—as in the liver, the kidneys, the lungs, the testicle, the lymphatic glands." (Rokitansky.) Encephaloid cancer is not usually solitary. It commonly co-exists in many textures and organs. Melanotic cancer—mostly a variety of encephaloid, by pigmentary degeneration of its cells, and the most common of all melanotic tumours —is prone to grow first, in or beneath pigmentary moles (Paget) ; or selects first the liver (Rokitansky) ; but it may occur " in the brain and about the nerves; at the eyeball, in the lungs, thyroid gland, liver, spleen, kidneys, bones, lymphatic glands, ovaries, in and beneath the in- testinal mucous membrane, between the mesenteric layers, in the skin and subcutaneous areolar texture, upon serous membranes, in the dura mater, upon and within the heart." This variety of cancer occurs as secondary formations, in very many textures and organs, simultaneously. Villous cancer—another variety of encephaloid—is produced, accord- ing to Rokitansky, exclusively upon membranes; more especially upon mucous membranes, and most of all that of the male urinary bladder, near the opening of either ureter; next to this the mucous membrane of the stomach, and in particular the pyloric portion. It has been observed suspended by a pedicle from the internal membrane of the rectum, and even from that of the gall bladder. Secondly, it is very apt to grow ex- tensively from the internal wall of ovarian cysts—cysto-carcinoma— Avhere it is recognised as villous cancer by its copious accompaniment of medullary sap. In these cases, it is often concurrent with cancerous in- filtration of the lymphatic glands about the lumbar vertebrae, and Avith peritoneal cancer—representing villous cancer upon a serous membrane. It has been observed also upon the dura mater; occasionally upon the general integument; and perhaps in bone. Lastly, it occurs in paren- chymatous organs. (2) Scirrhous cancer selects first the breast in the proportion of 95 per cent. (Pao-et.) Next, in order of frequency, the stomach; perhaps still more frequently, in this organ (Rokitansky); then, according to the last- named authority, the colon in its sub-mucous cellular tissue ; more rarely in the vaginal portion of the uterus; upon serous membranes, and in the subserous areolar tissue. Again, as an expansive degeneration of the omentum, and of the mesentery; .in the salivary glands; in the fibrous tissue of the bronchi. In several of these, as well as in other structures__for example, the ovaries and the brain,—there occur " can- cerous o-rowths of embryonic composition, and in all likelihood of fibro- cancerous (scirrhous) nature." To this list may be added cancer-growths secondary to scirrhus, and which, in proportion as they are consecutive, incline more and more to the condition of encephaloid; for example, of the lymphatic glands, the bones, muscles, skin. Scirrhous cancer is not unusually solitary. (3) Colloid-cancer selects the stomach and large intestine ; the serous 114 GENERAL PATHOLOGY AND SURGERY. membranes, and particularly the peritoneum. In other textures and organs this species is mostly secondary; as in the lymphatic glands, the lungs, the ovaries, the bones, the breasts; " and in rare cases, the kidney, uterus, and liver." (Rokitansky) : to which I may add, the pancreas, spleen, and urinary bladder. Colloid cancer is usually solitary. Origin.—Age has no definite influence on the production of Cancer; the three species having been known to originate at every period of life. Even during intra-uterine life, scirrhus in the heart was found in one case. At birth, meningeal cancer, and instances of cancer affecting other organs, have been found. In infancy, childhood, maturity, middle age, the decline of life, and extreme old age—even at ninety-three—cancer is liable to occur. But certain periods of life are prone to cancer growth, as indicated by its mortality; the tenth to the fifteenth year is least liable, the thirty-fifth to the eightieth year, and perhaps to a later period, is most liable, the tendency increasing with each succeeding decennial period. There seems to be a more rapidly increasing tendency after thirty and onwards for some years, as compared with the same number of years before that period; the proportion of deaths, in both sexes, from the age of thirty to forty increasing to six times more than between twenty and thirty. Sex much affects the liability to cancer. Thus, from forty to fifty years, in females, the mortality increases sixfold; whereas, in males, the number of deaths increases only two and a half times. Sex in relation to Species.—Scirrhus is more common in the female; epithelial cancer, in the male. Age in relation to Species.—Encephaloid occurs most frequently in infancy and youth; scirrhus, in adults, it being uncommon before puberty or even the thirtieth year; colloid in adults only, or excessively rarely, if ever, before the thirtieth year. Hereditary tendency.—Evidence in this direction may be resolved into two general facts. In some families cancer is known to have occurred in more than one individual. Mr. Sibley traced it among cancer patients at the Middlesex Hospital, in one case of every nine; by Mr. Paget, in one of every six cases. Mr. Arnott and Mr. De Morgan each had charge of members of a family in whom disease was thus exhibited; the father and his relatives were healthy, the mother died of cancer of the breast, two of her sisters of phthisis, and one of dropsy. Of six daughters, five had cancer of the breast, the youngest was still healthy, and the only son died of phthisis. On the other hand, to give some force to such obser- vations ; some entire families are exempt from the disease. Constitutional tendency to cancer can only be inferred—yet the in- ference is strong—from the apparently negative relation of this disease to any external causes. The various presumed external causes of chronic maladies shall continue in operation in many individuals, for a length of time with every degree of intensity and in all possible modes of combi- nation, without producing the slightest manifestation of cancer; and cancer exercises its most fearful ravages in persons who have never been influenced by any such causes. Excluding, therefore, external causes, some internal and individual, or constitutional tendency must have been in operation. On the other hand, there are reasons for believing that cancer, like syphilis, is primarily local, and only secondarily, constitutional. Vel- peau is, perhaps, the leading authority who supports this position; TUMOURS OR MORBID GROWTHS. 115 and the reasons adduced are thus stated by Mr. Erichsen in his work on Surgery:— (1) Cancerous tumours spring up in individuals who have always enjoyed perfect health, and who, to all appearances, are perfectly well at the time of the occurrence of the disease. (2) These tumours are not unfrequently the result of some local injury or irritation. (3) The constitutional health does not, in the majority of cases, appear to suffer until some months have elapsed ; when, as the lymphatics or glands become implicated, or neighbouring tissues invaded, signs of cachexy set in. (4) If the disease be removed before neighbouring parts have become contaminated, the health, if it have suffered, often improves materially. (5) The patient remains free from any recurrence of the disease for a considerable period; in the great majority of cases. (6) In some instances, no recurrence whatever takes place, the disease being eradicated from the system, which could not be the case if it were constitutional. (7) Recurrence having taken place soon after an operation, it is almost invariably either in the cicatrix or in its immediate neighbour- hood ; owing to cancer-cells which had been widely infiltrated escaping removal; and subsequently developing into a new tumour. Were the disease constitutional, recurrence would be as likely to take place in other parts, or in internal organs, as it does when the operation has been too long delayed. (8) The same tendency to recurrence after removal, and even to secondary deposit in distant organs,, is observed in respect to other tumours which are incontestably, primarily local—e.g., the fibro-plastic and the enchondromatous, and which only become constitutional in their more advanced stages, and in a secondary manner. This last proposition seems to me fallacious; both the tumours adduced being " localized " growths, although the fibro-plastic or myeloid variety of enchondroma is undoubtedly a recurring tumour. External causes.—Injury or irritation, is not found to have more than a limited influence on the production of cancer. A broken tooth scratching the tongue or cheek, may induce the disease in either of these parts; the friction of a clay-pipe, constantly used, may excite cancer of the lip; and the irritation of soot in contact with the scrotum or prepuce appears to induce the well known chimney-sweeper's cancer of those portions of integuments. In all such cases, the cancer produced is the epithelial variety. Effects of Cancer, as an internal cause.—(a) Locally.—Pain may be regarded as an effect, produced, apparently, by compression of the nerves in, and around, the cancer-growth; by separation of their fasciculi and fibrils with interstitial deposit; and, in the case of scirrhus by dragging of the nerves as the growth contracts. Pain is, therefore, due rather to a mechanical operation of the tumour, than arising from any vital endow- ment of the growth itself, which is in fact comparatively destitute of nerves. Encephaloid cancer, especially, is of this character; the tu- mour scarcely seeming to be sensitive, when cut into during a surgical operation for its removal.* Scirrhus, however, seems more especially to * System of Surgery. Edited by T. Holmes. Cancer, by C. H. Moore, vol. i. 116 GENERAL PATHOLOGY AND SURGERY. give rise to pain from within itself, the pain radiating thence along the nerves. The kind and degree of pain'vary considerably. Lancinating pangs, particularly when the tumour is handled, are commonly experienced in scirrhus. A hot dart, molten lead, and other such expressions are also used to denote both the character and severity of the pain in this species of cancer. The pain of encephaloid is generally less severe ; and colloid is comparatively painless. In cases taken indiscriminately the pain differs; a dull aching sensation, a feeling of weight and coldness, dis- tressing itching, represent these varieties. The pain varies also in point of date, duration, and constancy. Thus, it is not generally of early occurrence; being absent in most cases of scirrhous breast, for the first year or year and a half. Its duration is temporary ; occurring occasionally, as when the breast is handled. And cancer, not uncommonly, runs through its whole career without any .pain. It is absent in about one-fifth of the cases, including all organs and localities. (Walshe.) The pain is usually proportionate to the rapidity of growth; becoming more severe and persistent when the tumour is in- flamed or ulcerating or about to slough, and acquiring the hot burning or scalding character. Derangements of function are produced, some of which are irritative ; as pleurisy and hydrothorax by mammary cancer, peritonitis by ovarian cancer, vaginal discharge by non-ulcerated scirrhus of the uterus. Other derangements are mechanical; as effusions by the compression and ob- structions of blood-vessels, spontaneous fracture Avith cancer of bone, stricture of the urethra or bowel, pressure on the brain, spinal cord, or nerves, inducing paralysis, partial or complete, pressure on the optic nerve or from within the eyeball, impairing or destroying vision. (b) Constitutional effects.—The functions of the various parts of the body, other than of the part affected, may continue uninterruptedly for a longer or shorter period as cancer advances. Thus then the general health remains unimpaired, independently of the local disease. Conversely, the growth of cancer is inversely proportionate to the general health ; being temporarily arrested, if it remain unaffected or is maintained, and coming into activity as it declines. Consequently, with advancing age, there is, so far, a greater liability to cancer; and particularly of the uterus, during the decline of generative power. In like manner the functional vigour of any part of the body apparently protects that part against the production and growth of cancer; whereas the decline of such vigour has the opposite tendency. Thus, pregnancy and lactation protect the uterus and breasts, respectively; while the cessation of those functions is favourable to cancer-groAvth in these organs. The supervention of either of the functions referred to, is, howe\rer, sometimes accompanied with a rapid extension of* the disease, or the tumour may remain unaffected by these local changes. Cachexia is the term used to denote all those functional derangements, chiefly of the circulation, nutrition, and innervation, which together represent the constitutional condition. Feverishness, loss of appetite, nausea and vomiting, distressing thirst, imperfect digestion, obstinate constipation or diarrhoea, progressive emaciation Avith peculiar yellow sal- lowness, muscular weakness, sleeplessness, and melancholy; such are the leading phenomena of this condition. They are someAvhat proportionate to the amount and diffusion of cancer-groAvth in the system; and hence TUMOURS OR MORBID GROWTHS. 117 are more pronounced when it appears in different parts successively, as secondary cancer, and as affecting especially the great internal organs, which minister to the nutrition of the body. Cancerous cachexia is most marked in scirrhous, and least in colloid cancer; encephaloid taking an intermediate position, but being more nearly allied to colloid, in this its constitutional influence. Co-existing Diseases.—Diseases of various kinds may co-exist with cancer, without apparently influencing it, or being influenced by it. Thus, Bright's disease of the kidney has no effect on the course of cancer, which may proceed favourably, even to withering and complete cicatrization, independently. Extensive skin disease, syphilis, caries of the spine, fatty and cirrhosed liver, may severally co-exist. "But, observes Mr. Moore, exanthematous fevers are unknown in the cancer wards of the Middlesex Hospital, excepting erysipelas, which is not less common in such patients than in others. Erysipelas SAveeping over a cancerous ulcer Avill sometimes efface its specific characters, rendering it a healthy, granulating, and cicatrizing sore. In a few days, or weeks at most, the original kind of ulcer has reappeared. Hospital gangrene, occasionally, has a similar temporary effect, and ultimately the same result. Apoplexy and heart-disease seem to have some protective influence against the pro- duction of cancer. Tubercle appears to be no less manifestly incom- patible Avith cancer, while yet related to it." Traces of old tuberculous disease are remarkably common in the bodies of persons dying with cancer, and in 34 per cent, of them phthisis exists in the family; yet the two diseases are never found in active growth together in the same person. Active tubercle co-existing, supplants as it Avere, cancer, Avhich may wither and even cicatrize as the patient is rapidly dying of phthisis. Course.—In the vital history of cancer, certain aspects of its progress, subsequent to the more immediate effects already stated, are particularly worthy of observation. Rate of Growth.—Encephaloid cancer takes the lead, growing generally to some dimensions in a short time, or even Avithvast rapidity. Scirrhus grows more sloAvly. Colloid with a medium degree of rapidity. Duration of Growth.—Scirrhus is of longest mean duration, averaging three or four years; encephaloid is of shorter mean duration, aA^eraging about two years ; colloid holds a middle place also in this respect. Sex appears to have but little influence on either the rate or duration of growth. Age seems to have some influence; the progress of cancer, generally, being more rapid in the young, and chronic in old persons. Arrest and Decay.—These changes consist in a cessation of growing, and a destruction of the proper structural elements of the tumour. Cells and nuclei break up, oil-globules and granules are substituted. The chief element in a withering cancer is fat, thus contrasting with the general emaciation of the body. Softening—Avhich contrasts Avith the hard withering of cancer—takes place, principally, in encephaloid, itself soft cancer. It then consists of matter having a creamy or milky appearance, very slightly viscid, and the consistence of soft cheese or thin pus. The proportion of milky opake fluid, yielded on gentle pressure, indicates the progress towards this change. As affecting colloid cancer, softening represents, not perhaps any further change in its already jelly-like matter, but the breaking down 118 GENERAL PATHOLOGY AND SURGERY. of its containing stroma, with rupture of the loculi and escape of their contents. The commencement of softening, in any species of cancer, is either at the circumference or centre of the tumour; and in a single spot, or in several spots, simultaneously. Age seems to have no definite relation to these changes. In old persons, the arrest of cancer is not an uncommon event. One such case, under the care of Mr. Cooke in the Cancer Hospital, was that of a healthy-looking woman, with a ruddy complexion, and aged eighty-two. Scirrhus of four years' duration existed in her left breast, and she had been an out-patient just twelve months. Another instance, in the Uni- versity College Hospital, was that of a woman aged seventy-seven. The disease had existed for seven or eight years, but was progressive during the last eight or nine months. Terminations.—(a) Resolution and Absorption is one mode of spon- taneous cure. Thus, an encephaloid cancer of the eye of an infant ulti- mately disappeared, and was followed by dropsy and atrophy of the eyeball. Scirrhus of the breast disappeared in a lady whose other breast had been extirpated for this disease. But, in this case, scirrhus was found in several of the abdominal viscera; the patient having died of asthma not long after the subsidence of the breast-cancer, (b) Sup- puration is another mode of spontaneous cure. A man had a large scirrhous tumour removed from his back. The disease returned. No operation was again performed; but subsequently violent inflammation supervened, an abscess followed with profuse suppurative discharge, and then recovery, (c) Mortification may extirpate a cancer, though rarely. The Avhole tumour is eliminated by sloughing in a mass. [P. p. 808.] Cancerous Ulceration and Ulcer.—The former consists in the mole- cular disintegration or destruction of the structural elements of the textures, as in ordinary ulceration, preceded, however, by interstitial infiltration circumferentially; thus differing from ordinary ulceration. And the infiltrating cancer-elements, although themselves dying, seem to exercise a destructive influence over the proper textural elements. The ulcer resulting from this process, presents certain appearances which are most characteristic in the scirrhous ulcer. Of variable size and shape; the edges, at first perhaps thin, irregular, and level with the surrounding surface, or sunken, undermined, and inverted, become thickened, elevated, and everted—a condition commonly observed. The bordering skin acquires a bluish red, or brown tint; and the sur - face, excavated and irregular, presents large prominent granulations, or a base of slough and blood. A thin, greenish, foetid, and acrid dis- charge—ichor, oozes from the ulcer. Other changes may occur which more or less obscure these appearances, but they are chiefly exceptional or accidental. Haemorrhage, for example, may be profuse, and particu- larly from the ulcer of encephaloid cancer. The capillary vessels are the usual source of this haemorrhage ; but it sometimes proceeds from erosion of the larger vessels, or from rupture of the varicose veins communicating with the ulcer. An admixture of melanotic matter may occur, as seen also in the ulcer of encephaloid cancer. Then again, a cancerous ulcer is subject to those pathological processes which affect an ordinary ulcer ; as inflammation and phagedaena. A cancerous ulcer enlarges slowly or rapidly, both circumferentially and in depth, the whole area of the textures being infiltrated Avith cancer- TUMOURS OR MORBID GROWTHS. 119 elements. Consolidation increasing, the ulcer becomes firm and fixed, both in its margins and base; scirrhous ulcer especially acquires these characters, like this species of cancer in the course of its growth. Hard- ness and immobility, superadded to the appearances of margin and surface already described, renders the cancerous ulcer more characteristic. Cicatrization and Cicatrix.—Paradoxical as it would seem that any process of healing should take place in a cancerous ulcer—itself inherently destructive and texturally indisposed to heal—nevertheless, cicatrization supervenes occasionally. Unlike that of an ordinary ulcer, this cicatriza- tion rises over the prominent granulations and dips into the hollows of the ulcer. In the majority of cases, the process and its result are only temporary; as when erysipelas sweeping over a cancerous ulcer renders it a healthy cicatrizing sore, for a time. But, in some cases, the healing is established, and a sound cicatrix permanently formed. This has oc- curred in the ulcers of both scirrhous and encephaloid cancers. Of such unusual permanency, a case is related by Nicod, and several others were observed by Bayle. [P. p. 808.] The Cicatrix of a cancerous ulcer is, in some respects, peculiar. It is extremely thin, of a red or violet colour, and often traversed by large vessels. Contraction is restrained by the firmly adherent skin around, the cicatrix is thus rendered very tense and even more attenuated, and disposed to ulcerate again. Recurrence of Cancer, locally.—This is a very common event in the vital history of cancer, whether after its separation spontaneously, or re- moval artificially by the knife. Local re- production takes place under different cir- cumstances, which are classed, by Dr. Walshe, as follows.—(a) The process of cicatrization may not distinctly commence, or be interrupted at an early stage, and fun- gating growths spring from some part of the ulcer or Avound. (b) A perfect cicatrix forms, and after a variable lapse of time, a tumour grows in the subjacent tissues, presses out- wards the newly-formed scar, destroys it, and appears externally with the characters of cancer, (c) In the cicatrix itself, re- production may occur, by the development of tuberiform cancerous growths. (Fig. 26.) Encephaloid is the species of cancer usually presented, whatever was the original growth. Colloid perhaps never forms consecutively to either of the other species of cancer-growth. Recurrent cancer is said to grow more rapidly than the primary cancer. Dissemination of Cancer in the System,—Secondary Cancer.—(a) In textures continuous with that, or those, of the original growth. Con- tinuity of tissue is here the medium of communication, directly permit- ting of infiltration. The textures which thus convey the cancer-elements, may be naturally continuous, or connected by adhesions. Of the former, * Returning scirrhus in the breast, after operation ; presenting a series of nodules in and around the cicatrix. One in the centre has ulcerated. (Cruveilhier.) 120 GENERAL PATHOLOGY AND SURGERY. Mr. Moore saAV an instance where the only cancer in a lung was a small portion of an out-growing cancerous gland of the posterior mediastinum, and the only infected absorbent in the root of that lung was one of con- siderable size, not more than an inch from the implanted cancer, (b) In contiguous textures also cancer may, apparently, spread, without any direct medium of infiltration. Thus Dr. Hodgkin and other pathologists mention cases, in which an ovary, the mesentery, or the liver, being the seats of cancer—the parts in contact with those organs, as the intestine, the Avails of the abdomen, the supra-renal capsule or kidney itself— became similarly diseased, (c) In textures and organs remote from the original growth, secondary cancer may appear.—(a) The lymphatic vessels are undoubtedly one channel of transmission. The almost un- exceptional infection of the lymphatic glands in the neighbourhood of a cancerous growth,—and which is, indeed, one of the generically dis- tinctive characters of cancers, as a growth—supports this view. Such infection, in relation to primary cancer, is parallel to bubo, in relation to chancre. Either, however, may also be regarded as part only of the primary disease. But cancer can be traced further in the lymphatic system, progressively infecting glands more and more remote from, yet still directly connected Avith, the part in which the groAvth first appeared. Surely this diffusion of cancer is secondary. In only about one out of every forty-three cases of fatal cancer is there secondary deposit in in- ternal organs, without infection of the intervening lymphatic glands, en route, connected with the site of the external primary disease. (/3) The veins, and venous circulation, would appear to be far less a medium of transmission. Cancer-elements having entered the venous system, through the thoracic duct, the lung as the proximate organ, would next become the seat of cancer-deposit. Yet, in 173 cases of cancer, the lymphatic glands were infected in 140, the lungs in 22 only. The fact, however, of both these organs being affected, in most cases, and simultaneously, indicates the agency of the pulmonary venous system. (y) The arteries and arterial circulation are engaged even less definitely than the venous circulation. Arterial blood flowing to all parts alike, they are not equally prone to cancer. The liver is first in order, thus contrasting with the lungs, among internal organs. It was the seat of secondary cancer in 60 of 173 instances taken indiscriminately, and in 60 of only 90 cases in Avhich the disease spread at all beyond the lym- phatic glands of the part first affected. The kidney is far less liable, —it was attacked with consecutive cancer twice only in 173 cases ; and the spleen but once in that number. The bones and serous membranes, are both commonly invaded. These differences of liability suffice to show the extreme irregularity of secondary cancer, in its presumed relation to the arterial circulation, as the medium of transmitting cancer-elements from the primary growth. One general law respecting the dissemination of cancer in the system, would seem to be this ;—it is regulated, in some measure, by the reten- tion of cancerous matter within the body, or its discharge externally through the integuments by ulceration or through some natural passage. Cancer of the uterus with free discharge per vaginam, is folloAved by secondary cancer in not more than 25 per cent.; whereas deep-seated cancer of the breast produces secondary cancer in 79 per cent. In calling attention to this important general fact, Mr. Moore justly adds, there are covered cancers, though very few, which remain solitary to the TUMOURS OR MORBID GROWTHS. 121 end of life, and there are cancers on free surfaces which do become dis- seminated. The successive dissemination of cancer in the system, or primary and secondary cancer, must not be confounded with the simultaneous dissemi- nation of cancer, or the production of more growths than one, in different parts, at the same time. The total absence, probably, of functional symptoms, at an early period is apt to mislead—e.g., in cancer of the brain, lungs, liver, and stomach, organs of leading functional importance. Thus cancers which are apparently successive may really be simulta- neous. The relative tendency of the three species of cancer to affect the system secondarily, differs with respect to each. Encephaloid and scirrhus seem to dispute the first place in this aspect of their vital history. But colloid undoubtedly has here the lowest rank, as also in the other characters of malignancy. Species and shape of secondary cancer—Encephaloid is produced in the majority of cases; Scirrhus far less frequently, and even rarely. Colloid has not yet been found, in any case recorded. (Walshe.) The nodular form is that which secondary cancer usually assumes, especially in the liver, lungs, and bones. In a cicatrix, as after excision of a cancerous breast, this form of secondary cancer is very common. Nodules or button-like tubercles appear which spread and coalesce; or a hard ridge forms in the line of cicatrix. In either case the colour, whitish at first, deepens into a purplish-red hue. In proximate lymphatic glands, secondary cancer produces—and probably at an early period—tenderness, enlargement, and induration, increasing even to bulletty hardness. Termination by Death.—This, the natural and most frequent issue of cancer, takes place in various ways, which may be concurrent or succes- sive, (a) By the constitutional influence of the disease on nutrition and blood-production, as manifested by cachexia; the proper cancerous death. (b) The direct influence of the disease, locally, on various functions— e.g., of the liver, stomach, oesophagus, intestines, (c) Haemorrhage, in- ternally or externally—e.g., Cancer of the uterus, (d) Exhaustion from pain and discharge—e.g. Cancer of the uterus, (e) Mortification—e.g., cancer of the limbs. (/) Intercurrent diseases, generally of the inflam- matory class—e.g., pleurisy, or pneumonia, by cancer affecting the ribs and lung, (g) Substitute diseases—e.g., Phthisis supplanting cancer; tubercular deposit (in the lungs) being pathologically equivalent to the cessation of cancer-growth in some other part of the body. Treatment.—Naturally incurable and fatal as cancer is, generally, it may undergo certain structural changes of a self-curative character, the purpose of which it should be the aim of therapeutics—medical and opera- tive__to imitate. To establish this correspondence betAveen the treatment of injuries and diseases and the processes of Pathology, in respect to their natural courses and tendencies, is one of the leading features of modern Suro-ery; and this relation of art to the indications of nature, is better illustrated by the treatment of Cancer than by that of any other Morbid Growth. 1. Arrest of Cancer, and Hygienic and Medicinal Treatment.—The natural arrest and decay of cancer consists in the cessation of growth, and the disintegratiA'e destruction, of its proper structural elements; changes which are accompanied with, and denoted by, withering of the Tumour. 122 GENERAL PATHOLOGY AND SURGERY. This course and termination are observed mostly in the career of scirrhus, as witnessed best in the puckered-up chronic mammary cancer and shrivelled breast of old women. No known medical treatment seems to insure this result; although iron, bark, cod-liver oil, the anodyne influence of opium, and such other medicinal agents as, apparently, improve nutrition ; are auxiliary. But hygienic measures, especially in the shape of a generally nutritious and easily assimilated diet, and a cheerful, hopeful tone of mind, are most efficacious. The growth of a cancer-tumour is inversely proportionate to the arrestive influence of the general health. Thus, when the body is well nourished, the tumour starves. Local applications are advantageous resources occasionally. Any temporary supervention of inflammation may be treated accordingly, by a few leeches or a light poultice. Pain recurring or persistent, and affecting the general health, is often mitigated by a belladonna plaster, or by conium or opium ointment. A scruple of the iodide of lead in a drachm of glycerine, mixed with an ounce of unguentum opii, is recom- mended by Mr. Moore. Gently rubbed over the tumour two or three times a day, it reduces any swelling, as well as relieves pain. Soap plaster, used simply to protect, not to compress, the integument, is also calculated to retard the progress of the growth. Compression may control pain, but its efficacy in repressing growth is doubtful. First tried at the Middlesex Hospital many years since, it was unfavourably reported on by Sir Charles Bell; subsequently, highly extolled by Recamier—who stated that 30 per cent, of his cases were cured, and advocated by Dr. Walshe—it has, nevertheless, not found much favour in this country. Compression is best effected by means of the air-cushion and spring, devised by Dr. Neil Arnott. Pressure varying in force from two-and-a-half to twelve or sixteen pounds can thus be brought to bear on the tumour. 2. Sloughing and Enucleation • (a) by cauterization.—This method of treatment is warrantable only in cancer which is already idcerated, and has acquired adhesions beyond the fair reach of the knife. Cancerous glands, as an extension of the disease, are not so conveniently removed by the application of caustic. But they, and the textures around the slough, mostly become notably diminished in size; an important fact with reference to the glands, compared with their progressive enlarge- ment after removal of the primary tumour by excision. Velpeau's obser- vations seem to confirm this difference in favour of treatment by caustic. It may be followed by successful results, but of temporary duration ; a few weeks only—if the disease be incompletely extirpated, or lasting until after the wound has healed—if a healthy granulating surface was obtained. Subsequently, in either case, cancer reappears, in situ, and runs its course with rarely an exception to a fatal termination. As compared with removal by the knife ; the advantages of cauteriza- tion are, the bloodless character of the operation and, consequently, less exhaustion, and the less liability to erysipelas or pyaemia; the disadvantage is, the pain, severe and persistent. The caustics employed are, the concentrated mineral acids, sulphuric or nitric, or the solid caustic alkalies,—potash or lime, and various chlorides, that of zinc especially. Of all these, the glacial sulphuric acid mixed with powdered saffron—forming a black paste, is preferred by Velpeau, particularly in fungoid and bleeding cancers. The caustic alkalies combined, form the well-known Vienna paste. The chloride of zinc TUMOURS OR MORBID GROWTHS. 123 mixed Avith flour readily forms a paste by deliquescence. If a liquid caustic be used, the surrounding skin should be protected by a barrier of gutta-percha or other similar material attached to the skin. If chloride of zinc be used, the skin, which resists this agent, must previously be destroyed by sulphuric or nitric acid. The depth to which the action of any such agent extends and the destruction of the tissues accordingly, will depend on the strength and quantity of the caustic employed. But the result can only be roughly estimated. The slough produced varies in appearance with the kind of caustic employed; a dry, hard, contracted blackish eschar, resulting from the application of a strong mineral acid; a wet pulpy slough, from chloride of zinc. It separates after a time, a few days to a month, disclos- ing a healthy granulating surface, but perchance, of prodigious depth and extent. Other modes of applying caustic have, therefore, been devised. The repeated introduction of chloride of zinc through incisions daily made deeper and deeper, affords a precaution for limiting the slough to the depth and extent of the cancer. This plan of treatment was first practised in this country by Dr. Fell, of the United States; a Report on which was drawn up by the Medical Staff of the Middlesex Hospital, in 1857. Another mode is to undermine a cancer with caustic, introduced through narrow passages pierced with a seton needle. Of all these caustics and modes of their application, my own experience inclines to the chloride of zinc, which I first saw used by Mr. Liston about twenty-five years ago, and the efficacy of which has since been attested by its results in some cases. In the ulcerated stage of cancer, disinfectants are requisite, for the double purposes of cleansing the sore, and of counteracting the effects of that peculiar foetor which would otherwise encompass the patient in a self-created poisonous atmosphere. Charcoal or yeast poultices, and lotions of chloride of lime or carbolic acid, are thus beneficial. I can speak favourably of the latter poultice and lotion. They were remarkably efficacious in the case of a large cancer springing from the arm and in- volving the shoulder. Ulceration having commenced in front of the axilla and subsequently, in other parts of the tumour; the odour Avould have been intolerable to the patient but for these appliances. (b) Congelation.—The continued application of intense cold, is another means of destroying a cancer. Used in conjunction with caustic, congelation mitigates the pain, without diminishing the cauterization. Freezing is, alone, far less effectual. When most successfully practised, its destructive action extends not deeper than an inch; the only advan- tage then being the freedom from pain during and even after this process. As a method of treatment for cancer, it was introduced by Dr. James Arnott. Pounded ice may prove sufficient; but a mixture of ice, salt, nitrate of potash and hydrochlorate of ammonia, Avill freeze more thoroughly. The frigorific mixture should be circumscribed by gutta- percha or other pliant material, fashioned into a bowl around the part, with a tube to drain off the fluid as the mixture melts ; and the process must be continued for some hours. 3. Excision, or amputation, for the immediate removal of cancer, is the treatment most Avorthy of consideration. Granting the local origin of cancer, and thence the subsequent infection of the system; excision__as distinguished from any process of removal—is indicated, and at the earliest possible period. Hence also amputation, where practicable, 124 GENERAL PATHOLOGY AND SURGERY. may be preferable to excision—a partial operation, which may not thoroughly extirpate the disease. The delay of either operation, will assuredly allow the infiltrating course and adhesions of cancer to ensue, thereby rendering it locally impracticable or constitutionally useless. These pathological considerations suggest certain general reasons in favour of both excision and amputation, and their comparative advantages. (1) Extirpation of the disease, entirely and permanently. This is very rarely accomplished. (2) Temporary removal of the disease, and thence a proportionate restoration of ease and health. This immunity is always gained. The period of non-recurrence varies; perhaps less than one, it averages two years. Early performance of the operation may prolong this period to ten, fifteen, or twenty years. Such prolongation has been observed particularly in scirrhus affecting the breast. The experience of Velpeau and of Sir B. Brodie concur as to the long period of im- munity which may be enjoyed. (3) Prolongation of life. Comparing the duration of life in cases, without operation, and after : Mr. Paget states that, in the former case, the average period scarcely exceeds two years; whereas, in the latter, it extends to about twenty-eight months. Mr. Moore goes much farther, observing, that in 78 cases of cancer affecting the breast, not operated on, the average duration was 32-25 months; and in 57 such cases the average was 53"2 months. Any estimate of this kind is liable to a twofold error; the selection of cases for operation is generally those most favourable to life, and the probable mortality of the operation itself. The latter varies from 5 to 10 per cent. ; and albuminuria peculiarly predisposes to a fatal issue. Objections with regard to each of the three foregoing considerations may be raised as to the propriety of operative interference, but the same objections apply with equal or greater force to any kind of treatment whatever, in the course of a disease so, apparently, irregular as that of cancer. The conditions of cancer, or the cases which are respectively favourable and unfavourable for operation, may be stated, approximately, as follow ; cancer of the breast being taken as the type :— (a) Favourable for operation.—(1) A single tumour, not diffused, and whether in the nipple, on the surface, or in the substance of the breast. (2) When the nipple alone, or some portion of the skin, is drawn in towards the subjacent tumour. In either case, the superficial part not being widely infected but simply dimpled, the breast may be removed. But the disease is apt to return in and around the cicatrix. This took place in the case of a scirrhous breast which I removed in the condition described, a small portion of skin not larger than half-a-crown, being at- tached to the gland. (3) Ulceration of a cancerous tumour does not preclude operation, if in other respects the case be suitable. (4) The glands having become diseased to an extent which does not interfere with their removal, is a condition proportionately favourable for excision of the primary tumour. But the state of the glands cannot be exactly de- termined, otherAvise than in the course of the operation, and if then found to be cancerous, they also must be removed ; not necessarily, hoAvever, at that time, if such an enlargement of the operation might be perilous. Subsequently, and as soon as the health permits, the cancerous glands should be excised. This postponement I had recourse to in the case of a lady whose breast I removed for cancer; Avhen the Avound had healed, TUMOURS OR MORBID GROWTHS. 125 I then removed the axillary glands—by a more limited incision than a continuation of the original operation would have involved. The disease eventually returned in the breast-cicatrix. (5) Amputation of a limb is justifiable, although the glands show some hardening or doubtful enlarge- ment. This rule applies both to the encephaloid and epithelial disease. (6) Hereditary tendency, strongly manifested, does not entirely prohibit operation. In a family, of which six members were the subjects of cancer, one sister underwent excision of the breast in 1845, and another in 1846. Both remained well, until in each, Avith a recent recurrence of the disease, a second operation was performed in 1856—eleven and ten years after the primary operation. In 1859 both patients were alive. (7) Recurrent cancer may be removed under the same restrictions, as Avith reference to a first operation. My own experience of operation in such cases, is not favourable. In two—the original disease having been mammary cirrhus—one or two only small button-like nodules reap- peared in the cicatrix, these were at once removed, yet the disease speedily returned again. (8) Age does not prohibit the removal of a growing cancer. (b) Unfavourable for operation.—(1) Certain constitutional condi- tions—e.g., cancer co-existing, especially in some internal organ, or marked cancerous cachexia, albuminuria or other grave organic disease. (2) Diffused cancer and persistent oedema. But the latter condition is significant only when circumferential; oedema remote, depending on ob- struction to the circulation at the seat of disease—e.g., oedema of the hand from cancer of the arm, is not itself a prohibitive condition. In such case, I have seen the swelling subside and recur; apparently with varying states of the circulation as connected with the growth of the cancer above. (3) Adhesion, if at all extensive, either of the skin, or subjacent tex- tures, is decidedly prohibitive of operation. (4) Ulceration, otherwise than to a very limited extent and depth, is equally so. ' (5) Cancerous tubercles in the skin over a cancer, is a condition even more unfavourable for operation. Over a mammary cancer, increasing thickness of the skin, its widespread adhesion, and enlargement of the pores; constitute a de- cisive contra-indication. (6) The glands having become diseased to an extent which interferes with their removal, prohibits also removal of the primary tumour, either by excision or amputation. (7) Rapid growth, in any way, is decidedly unfavourable for operation. Hence most en- cephaloid cancers are better left alone, unless in a very early stage. (8) Cancers, the relations of Avhich to important parts around, cannot be foreseen, are better not meddled with. Thus circumstanced, are cancers beneath the scalp, Avhich often implicating the bone, penetrate the skull; cancer of the eye, Avhich often involves the optic nerve ; cancer of either jaw, particularly the upper, where it is apt to protrude into the maxillary sinus or the ethmoid cells; and cancers about the root of the neck. I once assisted my colleague Mr. de Meric in removing an encephaloid eancer situated about the sixth rib, beloAv the fold of the pectoral muscle on the right side. The tumour Avas not larger than an orange, the skin unbroken and it seemed moveable on the rib. Yret, on commencing the operation, the haemorrhage was alarming, the rib gave way, and any further attempt Avas at once discontinued. The man, of florid complexion, became blanched with almost fatal syncope in a moment, and rallying only for a short time, he died of internal haemorrhage ; a warning in all such, and similar cases. 126 GENERAL PATHOLOGY AND SURGERY. Epithelial Cancer.—One variety of cancer I have reserved for special description ; because, although in many points allied to encephaloid and somewhat to scirrhous cancer, it nevertheless presents very characteristic appearances, and possesses much surgical interest. I allude to epithelial cancer. Structural Condition and Diagnostic Characters.—This variety consists essentially of cells or scales, resembling those of scaly epithelium, infil- trated among the component elements of the skin or mucous membrane, or sometimes among the textures of internal organs. Whatever portion of the skin or mucous membrane may be thus affected, the epithelial cancer-cell or scale has very much the same characters. (Fig. 27.) It is flattened, of an irregular outline, with usually a prolonged diverticulum Fig. 27.* at some point of its margin, and of a variable size. It contains pale molecular matter, converging towards a central nucleus, which is clear, bright, and well-defined, round or oval, and very small in comparison with the cell; more uniform also in its shape and size. This nucleus is usually single. It may contain two or more minute granules, but rarely a bright distinct nucleolus. Associated with these cells, are what Paget calls " brood-cells," or endogenous cells. They present many varieties of appearance, which may be regarded as the results of one or more nuclei, enclosed within cells, assuming, or tending to assume, the characters of nucleated cells. The " laminated capsules" of Paget—" globes epidermiques," Lebert— are the most singular and characteristic structures of epithelial cancer, yet not peculiar to this disease; nor are they, apparently, special struc- tures, for they consist of epithelial scales. These capsules are very large and spherical cysts, containing granular matter, nuclei, or cells, obscurely seen within them; and clustered so as to almost appear as if fused together; but each capsule consists of epithelial scales, superimposed in successive layers, thus forming a laminated capsule. Such are the structural elements of epithelial cancer. They are found infiltrated—principally in the substance of the skin or mucous membrane— but not uniformly diffused throughout the component textures of the part affected. The cancer-cells may predominate in the corium, forming a swelling very slightly elevated above, or imbedded below, the proper level of the integuments, and the depth or thickness of which is much less than its dimensions laterally ; or these cells may predominate in the papillae, pre- senting a prominent warty or exuberant out-growth ; or, the sub-integu- * Epithelial cancer-cells or scales in various forms. Magnified 350 times. (Paget.) TUMOURS OR MORBID GROWTHS. 127 mental texture may be their chief seat, forming a deeper-seated, flat or rounded mass. Of these varieties, the first two may be named the superficial or out- growing ; while the third is the deep-seated form of epithelial cancer. Paget believes that either of these principal varieties may occur in any of the usual seats of this disease, but that they are not both equally common in every such part. The superficial, and especially those which have the characters of warty and cauliflower-like out-growths, are most frequently found on mucous membranes, especially of the genital organs; those also on the extremities and the scrotum have usually a well-marked warty character, and are rarely sub-integumentaL The deep-seated are more frequent in the tongue than elsewhere. It must not be forgotten, however, that these distinctions are more apparent than essential. Their value consists in reference to the earliest and most exact diagnosis of this disease, in whichever form it may chance to make its first appearance. For subsequently, and especially when ulcera- tion has commenced, an epithelial cancer which was superficial or exube- rant, is prone to extend into deep-seated parts; and one at first deeply- seated may grow out exuberantly. Moreover, when ulceration is progressing, a greater uniformity of external appearance is found; because, in general, while all that was superficial or exuberant is being destroyed, the base of the cancer is constantly extending, both widely and deeply, into the sub-integumental tissues. Respecting, then, the earliest appearances of epithelial cancer, the following are most diagnostic. 1. Of the superficial or out-growing, prior to ulceration, they are these:— (a) An outspread swelling arises—say on the lower lip, labium, pu- dendi, or scrotum ; and an unnatural firmness or hardness of the affected Fig. 28.* skin is perceptible; but the superficial dimensions much exceed the * Epithelial cancer of hand ; showing the papillary character, from specimen in the Museum of St. Bartholomew's. (Ser. x. i. 6.) The history of this case is in Pott's Works by Earle, iii. 182. The patient was a gardener, who had been employed in strewing soot for several mornings. The disease was of five years' duration. (Paget.) 128 GENERAL PATHOLOGY AND SURGERY. thickness of this swelling. Its outline is round, oval, or sinuous; and its surface, sometimes nearly smooth, is more often coarsely granulated—like that of a syphilitic condyloma—deriving this appearance from the enlarged and closely clustered papillae. Generally, the surface is moist with an ichorous discharge; it may, however, be covered with a scab, or en- crusted with a soft substance, consisting of detached epithelial scales. In most cases, the part is unduly sensitive, and injected Avith blood. If the papillae become infiltrated, they constitute the caulifiower-\ike mass so characteristic of the ordinary form of epithelial cancer. (Fig. 28.) This mass looks very vascular, is moist with ichor, and covered with pasty cakes of epithelial scales, which beset the interstices of the enlarged papillae. (5) Occasionally, the shape of an out-growing epithelial cancer is that of a sharply bordered circular or oval disk, upraised a little above the level of the adjoining skin, or mucous membrane, and imbedded to about the same depth below it. The surface of this disk—usually flat or slightly concave—is granular, spongy, or irregularly cleft; and its margins are surrounded with healthy texture, which becomes raised and often slightly everted by their enlargement—e.g., many epithelial cancers of the tongue. (c) Sometimes, epithelial cancer grows out in the form of a cone. (d) Lastly, the out-growing form of this disease may be a narrow- stemmed, and possibly pendulous, growth from the skin. These and other shapes of superficial epithelial cancer resemble some- what the appearances presented by warty and condylomatous growths ; but they differ essentially in respect of their minute structure ;—being infiltrations of the skin and papillae with epithelial cancer-cells; whereas the structure of warty-growths remains healthy, however strange may be the appearance they assume. 2. Deep-seated epithelial cancer is generally (a) an advanced stage of the superficial; for by progressive infiltration, the subcutaneous or sub- mucous tissues are invaded ; (b) but this variety of the disease may occur primarily, although comparatively rarely. " Thus," observes Paget, " the first formation of epithelial cancer may be in masses of circumscribed infiltration of the tissues, beneath healthy skin or mucous membrane." This condition is more frequent in the epithelial cancers that form, as recurrences of the disease, near the seats of former operations, or as secondary deposits about the borders of primary superficial growths." Situation.—Epithelial cancer selects either the skin or subcutaneous texture; or the mucous membrane; and of these textures the portions most liable are ranged by Paget in the following scale of frequency. First, its chosen seat is the lower lip, at or near the junction of the skin and mucous membrane; then the prepuce (glans, Rokitansky), scrotum of chimney-sweeps; the nymphae, the tongue; more rarely in very many parts; as at the anus, interior of the cheek, upper lip, mucous membrane of the palate, larynx (trachea, Rokitansky), pharynx and "cardia;" neck and orifice of the uterus (stomach, Rokitansky), rectum, and urinary bladder; skin of the perineum, of the extremities ; the face, head, and various parts of the trunk. In more rare instances, as a primary disease, it occurs in other than integumental parts ; as in the inguinal lymphatic glands, in bones, in tissues forming the bases or walls of old ulcers. Rokitansky has met with epithelial cancer only once in a parenchyma— namely, in the liver, and then encysted in a capsule of fibro-cellular TUMOURS OR MORBID GROWTHS. 129 tissue. By extension from its original seat, this growth may involve many deeper textures; fasciae, muscles, bones ; and as a secondary disease may, but very rarely, supervene in internal organs—the lungs, liver, and heart. Epithelial cancer, as a primary disease, is usually solitary. Occa- sionally, two or more co-exist, and even in the same part, as on the pre- puce and glans. Eventually, secondary epithelial cancer-growths may form in the tissues surrounding the primary and parent groAvth. Course.—The ulcerative stage of epithelial cancer is that in which the disease is usually seen ; and the usual state of ulceration observed is that of progressive destruction of the central and superficial parts of the cancer, with more than co-extensive groAvth of the marginal and deeper parts, thus constituting the type of the " cancerous ulcer." It is important, therefore, to be able to discern the first aspect of ulceration—both as regards the superficial and the deep forms of epithe- lial cancer, respectively ; and then, the characters of the complete ulcer. 1. Ulceration of superficial or out-growing epithelial cancer, primarily appears as either a diffuse excoriation of the whole surface of the cancer, except its borders ; or else a shallow ulcer limited at first to some fissure where the disease commenced. The discharge from this excoriated or ulcerated surface usually dries into a thin scab, or a thicker and darker crust; which conceals for a while the ravages of ulceration, still slowly extending beneath,—downwards and outwards. 2. Ulceration of deep epithelial cancer begins in one of three ways :— In some cases, the superimposed skin or mucous membrane having become adherent and thin, cracks; and this condition may remain sta- tionary for a long while, in the form of a dry dark crevice; but usually ulceration, commencing from this point, extends into the mass of the cancer. In other cases, the substance of the cancer having become inflamed, it softens, suppurates, and discharges its contents through an ulcerated opening, or a long rent; leaving a cavity Avhich speedily assumes the characters of an ulcer, and extends peripherally. In a third series of cases, and, perhaps, especially in secondary for- mations, and in those under the scars of old injuries, the cancer protrudes through a sharply bounded ulcer in the sound integument or scar, growing exuberantly, with a soft shreddy surface, like a medullary cancer, or with a firmer, warty, or fungous mass of granulations. Dissimilar as are the earliest aspects of ulceration in both forms of epithelial cancer,—out-growing and deep, they gradually assume an uni- formity of appearance which is very characteristic. 3. Complete Ulcer.—An excavated sore, of a round or oval shape, pre- senting a roughly granular surface, which has a brick-dust red colour, and oozes a stale-smelling discharge. This surface bleeds easily, although not freely. The textures surrounding its base and borders become indurated and rigid, as they progressively become more and more infiltrated with cancer-cells. The ulcer thus acquires a remarkable degree of immo- bility, and its margin protrudes in the shape of a thick everted ridge, Avell defining the boundary of the ulcer. Infiltration increasing, the marginal ridge forms an irregular nodular belt, which overhangs the base of the ulcer and gives an undermined appearance to its everted borders. If the papilla of the surrounding skin are more particularly the seat of cancerous infiltration, then a warty rather than a nodular belt K 130 GENERAL PATHOLOGY AND SURGERY. springs up around the ulcer. With all these signs of progressive infil- tration, followed by ulceration; the work of destruction is not stayed below the base of the already excavated sore. It spreads deeper and deeper, sparing no texture, not even large arteries, which hold out against the invasion of most other forms of ulceration, if indeed they do escape altogether. But arteries of the first magnitude yield to the unsparing ravages of epithelial cancer. Affinities to Cancer.—There are good and sufficient reasons for regard- ing this disease as a variety of Cancer. Its infiltrating character as a growth, is the essential guarantee of identity; while, its indiscriminate invasion of all textures, its ulcerative tendency, and unsparing destruc- tiveness, corroborate the malignant nature of this growth. Then again, the lymphatic glands are early liable, although not prone, to become affected by the continued epithelial infiltration of the primary growth ; but secondary formations thence arising are almost exclusively limited to glands in connexion with the immediate vicinity of the primary disease. A similar epithelial form of growth, or more commonly encephaloid cancer, may however secondarily spring up, indiscriminately in parts distant from the original disease ; and there is also the less significant fact of recurrence, sooner or later, after removal by operation. Lastly, in point of hereditary influence, members of the same family, in whom either scirrhous or encephaloid cancer occurs, are peculiarly liable to the epithelial form of growth. Duly Aveighing all these affinities, singly and collectively, this epithelial growth is rightly denominated epithelial cancer. In this conclusion the most able pathologists concur; Rokitansky, Virchow, Paget, and others. Epithelial cancer must not be confounded with the " Epithelioma " of Hannover and Bennett, who include under that title many other growths besides this A'ariety of cancer ; and it differs also from the " cancroid" of Lebert. Treatment.—The guiding indications of treatment in respect to epithe- lial cancer, are two ; one or other of which is always practicable. (1) To superinduce inflammation and sloughing, thus destroying the cancer. This may be accomplished by caustics; such as those already mentioned for the destruction of cancer generally; the strong mineral acids, caustic alkalies, and chloride of zinc. But it must be confessed that this method of treatment is not more successful in the one case than the ether. In one instance, of an encephaloid cancer of the entire cir- cumference and nearly the whole length of the Aragina, I repeatedly applied the strong fuming nitric acid by means of a glass brush; but without apparently any effect, for better or worse. (2) Removal of the cancer is the most effectual treatment. This may be accomplished by excision, ligature, or amputation. The former method is, generally, most eligible ; care being taken to cut sufficiently wide for the entire extirpation of the growth. It will be necessary to include any neighbouring lymphatic glands which have de- cidedly become, secondarily, affected by the cancerous infiltration. But the strong infiltrating tendency of epithelial cancer renders its effectual removal by excision doubtful. Removal by ligature, or the ecraseur, is the alternative method; wherever excision is impracticable, or Avould be imprudent, or inefficient. Amputation is necessary, primarily or secondarily, in certain cases. It may be so, in the first instance, owing to the extent of the disease, or DEGENERATIONS. 131 its locality, as when situated on the leg, or the arm, near the trunk. Of the latter urgency for amputation I had an instance in the case of an epithelial cancer just below the shoulder joint. [P. p. 633.] The patient died, after the operation, of Hospital gangrene. Secondary amputation is unavoidable in any case of recurrent-cancer; caustics, excision, ligature, or even primary amputation, as the case may be, having failed, perhaps successively, to extirpate the primary disease. CHAPTER III. degenerations. To clearly understand the significance of the term degeneration, it is necessary to bear in mind the nature of healthy nutrition, of Avhich physiological process, Degeneration is only another modification,—con- cluding the Pathology of Nutrition. The functions of the various organs and parts of the body, in health, are so adapted or adjusted as to constitute an evenly-balanced living or- ganization. And this co-operation is continued throughout life, in health. But the activity of all the functions—nutrition, for example—varies materially, during the successive periods of existence. After birth and with an independent existence, during infancy, youth and adolescence to maturity; the function of nutrition is yet more one of growth and development. During mature manhood or womanhood, this function is simply one of maintenance, to repair the muscular waste of the body consequent on the functional exercise of its various members and organs. Lastly, as age approaches, and during decrepitude, the nutritive poAver of the body proportionately declines. Waste is still repaired ; but the textural structure reproduced is an imperfect representation only, not a copy, of either its original or mature condition; it is a retrogression of textural structure, effected by a degenerative modification of nutrition. Degeneration is, therefore, only the concluding stage of the natural course of healthy nutrition, and as the concomitant retrogression of textural structure extends more or less throughout the body, and certainly per- vades vital organs, the whole organism retrogrades or reverts to the un- organized matter whence it came. Earth returns to earth, ashes to ashes, dust to dust. To die by degeneration is, therefore, as natural as to live by growth and development, and by the subsequent maintenance only, of nutrition. This function is, indeed, the consummation and resultant of all the other organic functions; and when in the order of nature they decline, nutrition declines also into degeneration, which it then represents. But this ultimate modification of nutrition is sufficient for life as age advances all other functions declining simultaneously and propor- tionately. The senile retrogression of textural structure, thus effected, cannot, in any sense be designated a diseased condition, nor the result of any morbid process. Nor again, when degeneration, natural to advancing and advanced life, occurs prematurely, can it then be regarded as a morbid process of nutrition, issuing in a diseased condition of textural structure. It is only premature old age; but the individual overtaken by degenera- 132 GENERAL PATHOLOGY AND SURGERY. tion is the subject of defective nutrition, and in this sense only, retrogres- sion of textural structure by degeneration ranks, and may be classed, with morbid products of Nutrition. Degeneration, Avhether senile or premature, is a form of atrophy ; but it is so by a deterioration of structural quality, not by a mere diminution of quantity. And, be it observed, this structural deterioration is effected by the relapse or falling back from a higher condition to a lower or more elementary grade of textural structure or even to an altogether structure- less condition. It, moreover, takes the place of or substitutes the proper elements of the original texture, which concurrently disappear. This relapse and substitution of textural structure, are the essential characteristics of Degenerative transformation. By substitution, it is dis- tinguished from the transformation of texture resulting from another and widely different cause,—Disintegration. Causes.—Analogy and facts alike concur to render the conclusion highly probable that degeneration, as being a modification of nutrition, is caused primarily by an appropriate blood-disease, in regard to each kind, of which it is the local and anatomical manifestation. On the other hand—as Mr. Paget observes—degeneration, like simple atrophy of quantity may arise from local causes, and apparently the same such causes; namely, diminished supply of arterial blood, as by partial closure of the chief nutrient artery of the part; or by abrogation or suspension of function. Furthermore, both degeneration and atrophy occur commonly in old age, but possibly prematurely; both also may occur simultaneously in one and the same texture, under precisely the same conditions; and, a cause of atrophy in one case may cause degenera- tion in another. In relation to disease, both may concur, as in inflam- mation ; or the disease, so called, may be only degeneration, as in simple softening of the brain or spinal-cord, and the liquefaction of inflammatory exudations during the suppurative process. General characters of Degeneration.—1. The new material is of lower chemical composition;—i.e., less remote from inorganic matter, than that of which it takes the place. Thus, fat is lower than any nitrogenous organic compound, and gelatine lower than albumen, and earthy matter lower than all these. 2. In structure, the degenerate part is less developed than that of which it takes the place : it is either more like inorganic matter, or less advanced beyond the form of the mere granule, or the simplest cell. Thus, the approach to crystalline form in the earthy matter of bones, and the crystals in certain old vegetable cells, are characteristic of degeneration; and so are the granules of pigment and of many granular degenerations; and the globules of oil that may replace muscular fibres or the contents of gland-cells, and the crystals of cholesterine that are often mingled with the fatty and earthy deposits. 3. In function, the part has less power in its degenerate than in its natural state. 4. In its nutrition, it is the seat of less frequent and less active change; and without capacity of growth, or of development. General Treatment.—The pathological indications of treatment, in re- gard to degeneration, are two :— 1. To elevate the condition of degeneration to some higher state of textural structure. This indication cannot be fulfilled by any known Hygienic or Therapeutic measures. The practicability of effecting DEGENERATIONS. 133 recovery from degeneration would seen to be inconsistent with the vital incapacity of a degenerate part for growth or development. 2. To counteract any further degeneration in an already degenerate part, or its extension to texture continuous. This indication may, perhaps, be accomplished by Hygienic and Therapeutic measures, either of which are general or topical. It would appear that whatever influence, of a preventive character, any such measures may have ; their action is mainly through the medium of the blood, by raising its quality and pro- moting its circulation. Hygienic measures, of a counteractive character, are, in general, such as have reference to the functions concerned in blood-production. Diet, selected Avith regard to the particular form of degeneration; pure air, friction of the skin, shampooing, baths warm or cold, regular exercise, and other means of promoting excretion, are thus highly important. Medicinal measures, within the present range of therapeutics, are less obviously counteractive of degeneration. Iron, cinchona bark, the mineral acids, and other tonics, may have some beneficial in- fluence, by improving the quality of the blood and invigorating the circulation; while aperients, diaphoretics, and diuretics, increase and regulate the excretions of the bowels, skin and kidneys. Some such resources are found in convenient, and apparently inimitable combina- tions, in the various natural chalybeate and saline mineral waters of Vichy, Wiesbaden, and other Spas. In such resorts, persons of " a broken or worn-out constitution"—subjects of degenerative changes of structure— experience a temporary revival of their failing powers, if not a permanent restoration to health. Rarely, any topical applications are beneficial; degeneration, of any kind, affecting internal organs, scarcely being influenced by such treat- ment. Special Kinds of Degeneration.—Pathologists differ as to the number and specific distinctions of the various kinds of degeneration. The classi- fication of Paget is not that of Dr. J. Hughes Bennett; nor this again, that of Dr. C. J. B. Williams. As this branch of Pathology stands at present, I would propose the following arrangement :—(1) Fatty degeneration; (2) Pigmentary ; (3) Fibrous ; (4) Amyloid ? Waxy, or Lardaceous; (5) Granular ; (6) Calcareous, osseous, or mineral degeneration. These various forms of degeneration are of much pathological interest to the student in Surgery, as well as in Medicine; and it is a subject upon which, respecting Fatty degeneration in particular, I have made a series of microscopic observations, both in animals and the human species. But, the distinctive structural and physical characters of each form of degeneration, and as taking place in the various normal Textures, new Products, as of Inflammation, and in Morbid Growths, are fully described in my work on " Principles;" and, as such degenerative transformations are little amenable to any special treatment—in addition to the general indications already noticed—it would be of insufficient practical impor- tance to here re-describe them. 134 GENERAL PATHOLOGY AND SURGERY. CHAPTER IV. ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. Death of any part of the body, as contrasted with its nutrition, is essentially a disintegration of the constituent elements of structure and resolution into molecular matter; the destruction of the organization which resulted from development; the falling to pieces of that which the formative power had constructed. Disintegration, like Degeneration, therefore denotes both a process and its result in the destruction of structure. Disintegration is related to Degeneration : the latter presupposes the former, but conversely, the former does not necessarily presuppose the latter; for Disintegration may occur independently, without any preced- ing Degeneration of texture. Ulceration, and Mortification including Gangrene, are essentially processes of Disintegration and textural death. But the pathology of these processes, and their difference in degree only, should be clearly understood. Ulceration.—A disintegrative process, essentially; the molecular matter resulting from ulceration may disappear in either of two ways:— Firstly.—By discharge, in the liquid form ; thus leaving a chasm or ulcer. Secondly.—By absorption through the lymphatics and veins jointly, especially the former vessels-; thus leaving a chasm or ulcer. " Ulcera- tive absorption" of Hunter. Possibly, both modes of removing the disintegrated textures co- operate in ulceration. The evidence in support of each such aspect of its pathology, is fully considered in the other work. [P. p. 513 et seq.~] The balance of evidence is, I think, decidedly in favour of the removal of the disin- tegrated matter by discharge. This matter can, indeed, be seen to come away occasionally; the molecular matter accumulating in the form of minute sloughs, whenever disintegration proceeds too rapidly for its dis- charge in the liquid form ; and again disappearing as molecular matter, when disintegration and discharge proceed evenly. Degeneration precedes the disintegration consequent on inflammation; and probably, therefore, precedes ulceration. The degeneration connected with inflammation, is usually fatty. Thus, it takes place in muscles, as shown by Virchow's observations, and perhaps in muscular tissue of the involuntary order—e.g., the heart, as in a case of fatal traumatic pericar- ditis examined by Mr. Paget; in bones, in the liver, and the kidneys, as shown also by Virchow; in the cartilages, as noticed by Redfern ; and in the cornea, by Strube. Calcareous degeneration may be the prior textural change. It takes place in chronic rheumatic arthritis; with inflammation of the laryngeal cartilages; and the formation of imperfect dentine, with inflammation of the tooth-pulp, is, perhaps another illus- tration. ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 135 The proper discharge from an ulcer—the product of ulceration, not that of a granulating sore—is ichor, the nature of which is not well understood. Ichor, is usually a thin sanious fluid, colourless or slightly yellow; structureless, but mixed with exudation, pus, and blood corpuscles, and with the disintegrated matter or debris of the textures. Its chemical composition, as to the essential constituents of this fluid, is unknown. Its chief property is corrosiveness; the operation of ichorous discharge main- taining and extending ulceration. Diagnostic Characters of Ulcers.—An ulcer differs widely in appear- ance. Ulceration forms a chasm of very variable extent and depth, from the slightest abrasion of the integument to the deepest cavity down to and into the bone; it is found less frequently as such, than accompanied with granulations of some description, overspreading the whole or part of the surface. The circumferential margin of the ulcer varies in thick- ness, and in direction; being turned inwards and perhaps undermined, everted, irregular, or tolerably even; its colour and that of the surface may be red, dusky brown, livid, or otherwise shaded; while the ichor or dis- charge varies greatly in quantity and quality from the typical characters already stated, through every description of mixed discharge, or even healthy pus. All these different appearances proceed, generally, from constitutional conditions ; but, occasionally, they are produced by external causes acting locally on the part; as by friction, filth, or various topical applica- tions and dressings. Two classes of ulcers, therefore, each including subordinate varieties, might be recognised with reference to their pathological origin; but, practically, it may be difficult to draw this line of distinction. Hence the distinctive species and varieties of ulcers are differently enumerated by authors; the nomenclature also differing accordingly. The following species present, perhaps, the most distinctive characters:— (1) Healthy or typical Ulcer. (2) Inflamed. (3) Irritable. (4) CEde- matous. (5) Indolent, and Varicose. (6) Phagedaenic. (7) Haemor- rhagic. (8) Scorbutic. (9) Scrofulous. (10) Cancerous. (11) Lupoid. (12) Syphilitic. (1.) Healthy or Typical Ulcer—consequent on a wound or other injury, or the separation of a slough; an open sore thus formed, in a healthy person and itself in a healthy state, presents certain characters, of variable extent, depth, and shape ; the surface is uniformly mammillated with small florid granulations ; Avhich, however, do not bleed readily and are not painfully sensitive. Healthy pus, opaque, yellowish, and of creamy consistence, more or less in quantity, bathes this granulating surface. The margin of such an ulcer shelves gently down to its base, and is scarcely perceptibly harder than the adjoining healthy skin. The neAv skin, corresponding to the margin, has an opaque white colour, and its formation is preceded by a linear translucent film of cuticle, which, veiling the subjacent granulations, has a bluish-white tint. The granula- tions immediately within this line are more florid than those nearer to the centre of the ulcer, because more vascular where the cuticle and skin circumferentially, are being formed. The surface having reached the level of the skin, by granulation, and the formation of pus,—superfluous organizable material,—having ceased; cicatrization proceeds imvards by the continued formation of marginal 136 GENERAL PATHOLOGY AND SURGERY. skin, preceded by cuticle, and thus, at length, presents the characters of healthy cicatrix, in the recent state. [See Reparation by Granulation.] Treatment.—Little or no positive treatment is requisite, a healthy ulcer healing spontaneously, provided any circumstances adverse to the process of reparation be excluded. Rest, position, to prevent tension and any undue determination of blood, and protection of the surface by Avater- dressing; are sufficient. (2.) Inflamed Ulcer.—A departure from the healthy type of ulcer; the usual signs of inflammation are characteristic. An area of redness with some swelling around the ulcer are more or less conspicuous appear- ances ; while a burning heat and aching pain are experienced, particularly when the part is pendent, as the shin, a common situation for an inflamed ulcer. The granulations have a rose-red rather than a florid colour, or they may be absent and the surface of the ulcer overspread with a thin ash-grey slough ; the suppuration is scanty, thin, and perhaps tinged with blood. As inflammation subsides, the cuticle peels off or desquamates for some distance around the ulcer. This condition of sore accompanies inflammatory fever, an ulcer pre- viously healthy then becoming inflamed; or it may be produced by ex- ternal violence or consequent on local irritation. Treatment.—Any cause or causes in operation will, as usual, primarily direct the treatment, namely, their removal. Then, remedial measures are those appropriate for inflammation. A poultice, or a cold evaporating lotion, if more agreeable, and perhaps the local abstraction of blood by a few leeches applied in the neighbourhood of the ulcer; Avith rest and an elevated position of the part, and, finally water-dressing as the sore assumes a healthy character and undergoes the process of healing. Ban- daging the limb, may, at this period, be useful to support the weakened vessels of the part, and thus prevent any liability to the continuance or recurrence of a low state of inflammation; a very troublesome chronic condition, which is apt to follow an acutely inflamed ulcer. (3.) Irritable Ulcer.—This variety of ulcer is to be distinguished from an inflamed ulcer, with which it might be confounded. Painful to a degree, even of a neuralgic character, the other and more peculiar signs of inflammation, particularly circumferential redness and SAvelling, are wanting. The granulations are imperfect, or absent, reddish here, tawny there; but they are very painful and sensitive to the touch, and readily bleed on slight pressure or the application of a stimulant dressing. The discharge is thin and sanious; and the edge of the ulcer, irregular, sharp, and abrupt, evincing no disposition—not to say an obstinate indisposition —to commence cicatrization. Commonly situated on the shin or lower part of the leg ; an irritable sore or fissure of the anus not unfrequently occurs, which well illustrates the pain and other characters of this variety of ulcer. It is generally connected with some disturbance of the digestive organs, and with con- stitutional irritation as distinguished from inflammatory fever. More rarely, some cause of local irritation may co-operate: as the passage of the faeces and the contraction of the sphincter-ani muscle with regard to irritable ulcer in ano. Treatment.—The removal of any cause in operation is the primary consideration. Hence the rectification of the constitutional disorder, by saline purgatives and mercurials to influence the secretion of bile. Then, opiatesoccasionally,Avill do much to allay the general irritability. Of topical ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 137 applications, nitrate of silver freely applied is the most efficacious. Lead and opiate lotions may also be recommended. Rest of the part is neces- sary or advantageous, as in the treatment of other ulcers; and thus, di- vision of the sphincter-ani muscle by incision through a fissure of the anus, will relieve pain and facilitate granulation in that situation. In any case of irritable ulcer, as healthy granulations spring up, the pain subsides; and the cicatrix formed is not more than ordinarily sensitive. (4.) (Edematous Ulcer.—In this variety of ulcer, the granulations are large, pale, translucent and flabby, sometimes cropping-up as large gelatinous masses above the level of the sore. The discharge is watery, and the margin has no disposition to commence cicatrization. Indeed, the granulations are apt to slough. This condition arises in connexion with a weak circulation, or it may proceed from the soddening of an ulcer by continued poulticing or other prolonged application of moisture and warmth. Treatment.—In addition to the removal of any constitutional or local cause; local treatment is often remarkably curative. An elevated position, astringent lotions, as of sulphate of zinc or nitrate of silver, and the support of a bandage; will probably succeed in reducing the granu- lations to the level of the ulcer, when exuberant, and strengthen their vitality, thus favouring cicatrization. (5.) Indolent, and Varicose Ulcer.—A deep and, perhaps, large excavation, presenting a flat surface,—without granulations, of a dusky or pale colour, scarcely sensitive to the touch nor disposed to bleed, and having a firm, hard base adherent to the subjacent fascia. A thin offensive discharge exudes. The edges are everted, thick, and callous, and of an opaque-white colour,—owing to accumulated epidermis; the surrounding integument to some distance being congested, of a dusky hue, and pigment stained, thickened, hardened, and bound down to the textures beneath. Such an ulcer is obstinately indisposed to heal. It is commonly situated on some part of the leg. An ordinary—non-specific—indolent ulcer does not seem to be depen- dent on any constitutional disorder; but it is apt to occur in weakly, ill-nourished, and perhaps ill-fed persons. The varicose ulcer, is a variety of indolent ulcer, and so named from its connexion with a varicose condition of the adjoining veins. Re- sembling generally an ordinary indolent ulcer, it differs in certain tolera- bly distinctive characters. Situated on some part of the leg, commonly on the inner side tOAvards the ankle, and single ; in the recent state it is of small size, ovoid shape, and with its long axis in the direction of the limb : without granulations and firm, a bluish-purple colour of the base and more so of the margin and surrounding integument, is conspicuous, and the ulcer is not unfrequently painful and sensitive. Inflammation and sloughing, or other conditions, may temporarily veil these appear- ances ; but the tortuous, knotty enlargement of the venous trunks, or the more diffused mottling of smaller varicose veins, with, perchance, a broAvn- ish-red pigment stained skin around the ulcer, is still a characteristic ac- companiment. In the progress of varicose ulcer, an occasional event of practical importance is venous haemorrhage ; arising from the ulceration having penetrated an enlarged vein, it may occur suddenly and copiously. Treatment.—An indolent ulcer cannot cicatrize so long as it and the surrounding integument are both bound doAvn; the margin being upraised and retracted, and the base depressed. Accordingly, pressure 138 GENERAL PATHOLOGY AND SURGERY. and stimulation conjoined, represent the plan of treatment. The nitrate of silver freely applied to, and around the ulcer, or the continued application of zinc ointment, with tolerably firm bandaging may bring it into a healthy condition. A more even and constant pressure is secured by strapping the limb with strips of linen spread Avith soap- plaster, mixed Avith a little adhesive plaster to fix it. Drawn around the limb, from the side opposite the sore, each strip in succession should partly overlap the preceding one, and the ends be crossed obliquely; thus forming a compact casement, and which should extend two or three inches above and below the sore. Blistering circumferentially, softens and loosens the integument, and may thus tend to facilitate cicatrization. Incisions have been recommen- ded to allow the granulations to contract; and, in most obstinate cases, transplantation of a portion of adjoining healthy integument, sufficient to close in the ulcer, may be tried ; with the view of forming a substitute- cicatrix. Of these three resources, I am decidedly in favour of blis- tering. Opium seems to have some special influence in rendering the granu- lations florid, and promoting the healing of an indolent ulcer. It is therefore, advisable to keep the system under this influence by the re- peated administration of opium, in small doses. Stimulants, tonics, and a generous diet, will often prove beneficial. The varicose ulcer is amenable to the same plan of treatment; but the varicose state of the veins, as the cause in operation, is an additional and the special object of treatment. An elevated position of the limb to relieve congestion, and an elastic bandage or stocking to equally support the vessels, will prove sufficient for this purpose, in most instances. When the ulcer has healed, it may still be necessary to wear an elastic stocking, as a preventive measure. In more obstinate cases, and with the view of a permanent cure; obliteration of the larger veins may be re- sorted to. Of the many means devised, the safest and most successful, in my experience, is the folloAving:—A hare-lip pin is passed underneath the vein, and another at a point about an inch distant. Care must be taken that the vessel be not transfixed, a misadventure easily avoided by dip- ping the pin, and readily discovered by the escape of a drop or two of venous blood. If the vein be transfixed, the pin should be withdrawn and introduced at another point. A ligature passed round either pin in a figure of eight fashion, will compress the vessel sufficiently to cut off all communication with the venous blood in either direction, and thus isolate the portion of vessel between the pins. Division of the vessel in that situation subcutaneously, as recommended by Mr. Lee, will then more thoroughly ensure its obliteration. (See Veins.) Several such intercep- tions may be necessary at different points in the course of the saphena vein ; in Avhich case the highest pair of pins should be introduced first. The pins must be allowed to remain for about a Aveek. I do not find the tendency to slight ulceration of sufficient importance to require the pre- caution generally recommended, that of protecting the vein with a piece of bougie before applying the ligature. After this operation, in no case have I seen any perilous consequence, such as phlebitis or pyaemia, but diffuse or erysipelatous inflammation ensued for a while, in one case. In some instances, after the lapse of a year and a half or two years, oc- clusion of the vein has still been complete, a permanently successful result which has allowed of active exercise Avith comfort; in other cases, the ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 189 varicose condition has returned, as the only unfavourable issue; while in yet a few, it has remained on the removal of the pins, and a repetition of the operation has altogether failed. Venous haemorrhage, occurring in the course of a varicose ulcer, may be arrested by a compress of lint, secured by a bandage, over the aperture in the vein which has given way; and by elevation of the limb. (6.) Phagedenic Ulcer.—Essentially a spreading ulcer, it is charac- terized by dusky red discoloration and swelling, with perhaps acute pain around the ulcer ; a grayish, glutinous or slimy slough, which exhales a peculiar foetid odour, occupies the surface of the sore, and the edges, sharp, irregular as if worm-eaten, and undermined, fall away rapidly; thus enlarging and deepening the area of the ulcer. Sloughing may pre- dominate in such ulceration, and hence sloughing and phagedaenic ulcers are not uncommonly associated. Sooner or later, constitutional disorder ensues; irritation rather than inflammatory fever, with great weakness and exhaustion. Allied as this condition is, in its local and constitutional characters, to Hospital gangrene ; it would seem that such gangrene arises from an external cause,—contagious matter applied to a sore ; the constitutional disorder being secondary and symptomatic, although in its turn affecting the ulcer. On the other hand, habitual deprivation of food, the abuse of stimulants, or living on spirits, and, perhaps, overcrowding, Avith destitu- tion ; seem to give rise to phagedaena. Treatment.—To arrest the rapidly spreading ulceration, a free appli- cation of strong nitric acid, by means of a glass brush, is most effectual. Followed by poultices, the slough, thus formed, is detached, exposing pro- bably a healthy surface, which has acquired a healing character. Re- application of the acid may be necessary, or the continued application of yeast, charcoal, or chlorinated poultices may be sufficiently stimulant and cleansing ; and, at the same time, disinfectant. Opium, administered in small and repeated doses, so as to keep the system under its influence, is most potent in allaying the irritative fever ; while the strength of the circulation and healthy nutrition, are restored by quinine, the mineral acids, and a generally nourishing diet. (7.) Hemorrhagic Ulcer.—Any variety of ulcer may assume this cha- racter, but some more particularly—e.g., the irritable, phagedaenic, vari- cose, cancerous, and, perhaps, lupoid ulcers, by the penetration of a blood- vessel ; and the scorbutic ulcer, by passive haemorrhage owing to the blood-condition. Not unfrequently, an ulcer oozes blood about the catamenial period, and especially in women suffering from amenorrhoea; the haemorrhage then being vicarious menstruation. An ulcer thus acquires a bloody, clotted appearance. Treatment.—Arising from such various causes, an haemorrhagic ulcer is a contingency rather than any special variety of ulcer,—and should be treated accordingly in connexion Avith Avhatever ulcer it may be associated; by reference to the particular condition, local or constitutional, which causes the haemorrhagic character. (8.) Scorbutic Ulcer.—Although scurvy in itself—observes Mr. Busk —cannot be said to be attended Avith any peculiar form of ulceration, ulcers or sores of any kind already existing from other causes assume, in con- sequence of the scorbutic taint, a more or less peculiar character, and Avhenthus modified have usually been termed " scorbutic ulcers." It is the 140 GENERAL PATHOLOGY AND SURGERY. effusion of a semi-plastic fibrous material—the same as that which causes the spongy swelling of the gums, &c.—on the free surface of sores or ulcers, which gives them the peculiar aspect termed scorbutic. Ulcers of this kind are distinguished by their livid colour, irregular tumid border, around which no trace of cicatrization is evident; whilst the surface of the sore is covered with a spongy, dark-coloured, strongly adherent, foetid crust, whose removal is attended with free bleeding, and is followed by a rapid reproduction of the same material. This crust, in bad cases, as remarked by Lind, attains to a "monstrous size," and constitutes what has been appropriately named by sailors " bullock's liver." Treatment.—Regarding a scorbutic ulcer as but a manifestation of the blood-disease—scurvy, the appropriate treatment is that which pertains to this disease; and having regard to its apparent dietetic cause, namely, the deprivation of fresh vegetables, remedial measures will consist, chiefly, in their restoration. Hence the well known efficacy, preventive and curative, of potatoes and of lemon or lime-juice. (9.) Scrofulous or Strumous Ulcers.—Consequent on the ulceration of a scrofulous tubercular swelling, or the opening of a scrofulous abscess, the ulcer is remarkably indolent, yet its characters are unlike those of the ordinary indolent ulcer. Large, pale, flabby granulations, sometimes exuberant, with a gleety discharge, form the surface of the sore; the margin is thin, livid, and undermined, sometimes pretending to heal by encrustation of the discharge. The characters and tendency are those of an ordinary oedematous ulcer; but a scrofulous ulcer is even less disposed to heal soundly. A scrofulous cicatrix appears drawn, puckered, and in- complete. Small bridges form across the ulcer, underneath which a probe can be passed readily, in and out, here and there. Nature does but " skin and film the ulcerous spot." The co-existence of scrofulous swellings and abscess, in other parts, will complete the diagnosis. Such ulcers are most frequent in the neck, groins, cheeks, scalp ; and about the knee, ankle, wrist, and elbow. They are often numerous and clustered. The immediate cause in operation would appear to be a blood-disease, the nature of which however is unknown. But whatever impairs the nutritive qualities of the blood and its circulation, predisposes to scrofula. Hence deficient or defective food, insufficient ventilation, want of cleanli- ness and excretion, poor clothing, cold, damp, and even dark localities, with other hygienic conditions of similar import, are the nurseries and nurses of this blood-disease. Individual predisposition, as usual, plays its part; for among a family of children in precisely the same hygienic cir- cumstances, one becomes scrofulous, while the rest remain free. Treatment.—In addition to the removal of any adverse hygienic con- dition; iron, bark, and cod-liver oil, are calculated to strengthen the circulation and improve nutrition. The digestive organs will also require watchful attention. A stimulating plan of treatment with moderate pressure on the ulcer is appropriate, as for an oedematous ulcer. Thus, nitrate of silver or sulphate of copper, and bandaging, are beneficial as topical appliances ; but the more important part of the treatment is con- stitutional. The scar of a strumous ulcer is unsightly and may occasion defor- mity, either by contraction or, more commonly, by over-growth, and the formation of bars raised in radiating lines, or net-works, or tongues of skin. In such cases—observes Mr. Paget—excision of the scar may be ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 141 necessary ; but in many instances a great portion of the excess of scar can be removed by repeated slight blistering, and with time nearly the whole will level down. In a superficial scrofulous ulcer on the hands or feet, excessive growth of the papilla at the base or borders of the ulcer, gives a remarkably warty character to the ulcer ; Avhich often remaining after cicatrization, leaves a coarse, nodular, patch of skin, with opake, thick cuticle. In this particular resembling a papillary epithelial cancer; the diagnosis of this form of scrofulous ulcer may be determined, by the absence of hard- ness in the granulations or the base, of a sinuous or upraised border, and of rapidity of progress ; and by the presence of more than one, perhaps many such ulcers. These warty strumous affections may be cured by repeated applica- tions of iodine-paint. (10.) Cancerous Ulcer.—Already described in this Avork, as part of the general history of cancer ; the characters of a cancerous ulcer are here alluded to as compared with those of a lupoid ulcer. The scirrhous ulcer is most distinctive. Beginning in the skin and extending down to deeper textures, or commencing subcutaneously—in a cancerous mass, and extending upwards to and involving the skin; the ulcer formed in either way, presents an irregular cavity, the surface of which is covered with large, hard granulations, discharging a thin, peculiar smelling ichor ; the edges are elevated, thick, and everted, with much circumferential indu- ration. The neighbouring lymphatic glands are, or become, indurated, and enlarged. The ravages of this ulcer are unlimited. Treatment—see Cancer. (11.) Lupoid Ulcer.—Commencing as a fissure or soft wart; the ulcer formed is an excavated hollow, having, commonly, no granulations, the edges sharp and worm-eaten, with no induration around. The lymphatic glands are unaffected. But this ulcer, also, spreads and spares no texture. As contrasted with a cancerous ulcer, the differential characters, above stated, were early impressed on my mind by tAvo well marked cases wdiich I observed when a student at the University College Hospital. The one, an elderly Avoman—under the care of Mr. Morton—had a large cancerous ulcer of the leg, which presented the appearances I have described ; the other, a middle aged man, an ostler,—under the care of Mr. Liston—had a large lupoid ulcer of the cheek, Avith the appearances already noticed,—namely opposite to those of a cancerous ulcer. Treatment.—Various powerful escharotics have been tried with the vieAv of arresting the progress of a lupoid ulcer, and converting it into a healino- condition. Chloride of zinc, mixed with flour and forming a paste by deliquescence, Avas used in Mr. Liston's case. The intense pain, for a time, which followed its application, would now-a-days be subdued by the continued influence of chloroform. Subsequently, poultices, help to brino- away the slough. Further extension of the ulcer may be thus arrested and the cavity evince a tendency at least, to heal. This favourable change took place in the case alluded to, and I have since met Avith similar instances. Iron, bark, and cod-liver oil, and other means of improving nutrition, seem to have some beneficial influence. (12.) Syphilitic Ulcer.—Primary, secondary, and tertiary syphilitic ulcers form part of the general pathology of Syphilis. Mortification.—The transition of ulceration to mortification, as already noticed, will have suggested their mutual relation. As processes, 142 GENERAL PATHOLOGY AND SURGERY. they differ in degree, but are one in kind. The former may be exag- gerated into the latter, and this again may subside into that. Ulceration and mortification are convertible by gradations of the same process, disin- tegration of structure ; the one, molecular, as a liquid discharge ; the other en masse, presenting accumulations of disintegrated matter. Thus, during ulceration, ever and anon some temporary cause may accelerate the process; a larger portion of tissue undergoes disintegration than can con- currently pass away as discharge; a portion of such matter then appears as slough, instead of having disappeared imperceptibly—molecule after molecule—in ichorous solution. It is as if the " flow " of a tidal stream washed up more material than the returning " ebb " can well recover— the line of coast shows the remaining d6bris. Even so, the surface of an ulcer may present a rim of slough, and from time to time, another and another, as the margin of the sore recedes and extends. Signs.—Gangrene, or the incipient stage of mortification, exhibits certain characteristic appearances. (Fig. 29.) The skin is livid or has a black hue, shading off to a reddish brown around the dying part. Its consistence is changed; becoming soft, with considerable SAvelling and Fig. 29. pitting on pressure, while the cuticle is raised into vesicles containing a yellowish serum or, phlyctenae—large bladders, full of bloody serum. The part is, in fact, altogether sodden and succulent, from the infiltration of Fig. 30. the constituent cellular texture with serum. This condition is the humid gangrene of French authors, the hot of German writers, and the acute of our own school. (Fig. 29.) Or the part may be hard, shrunken, and dry. An ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 143 opposite condition, known as dry, cold, or chronic gangrene. (Fig. 30.) In either state, the sensibility of the part is diminished, and its tempera- ture reduced. The odour of gangrene is peculiar and pungent; it be- comes foetid with the evolution of gas by decomposition, which, inflating the cellular texture, much increases the swelling; and owing to the admixture of gas and serum, it then has the additional character of crackling under gentle pressure, or of fluctuation like a collection of pus, if the deeper textures be thus distended. The part is irrecoverably dead; mortification having advanced to its second and furthest stage— the condition of sphacelus. The textures, in this condition also, may be dry and shrunken ; as in senile gangrene which has advanced to sphacelus. In either case the part is insensible and cold. The anatomical condition of sphacelus is somewhat peculiar. Disin- tegration of the soft textures still prevails; the bones, indeed, may have undergone but little change, otherwise than appearing dry and bloodless, their periosteum being detached ; but the articular cartilages and tendons are dull and slightly softened, while all the softer textures have broken down indiscriminately, with one exception. The bloodvessels alone have escaped destruction. Thus, phlegmonous erysipelas may have laid bare several inches of the femoral artery, by sphacelus of the integuments, and yet that vessel remain intact. The blood also—stagnant and coagulated therein, after death—may remain fluid and circulating during life; or coagulation having taken place the vessel will be impervious, and perhaps to some distance above the seat of sphacelus. Hence the absence of haemorrhage during amputation in such cases. Causes—external and internal ; and their operation.—The pathology of ulceration and mortification being essentially the same, their etiology also is the same. External agents : physical—as mechanical violence and injury, heat, cold, electricity ; chemical decomposing agents; and vital, as animal poisons introduced into any living texture. Either of these external causes may immediately kill the part, or kill, if the tissue be vascular, by inflammation supervening and terminating, perhaps speedily, in mortifica- tion. (1.) Violence or injury of any kind may give rise to gangrene, which is thence denominated traumatic. It is thus distinguished from gangrene arising from any internal, and commonly constitutional disease—e.g., a blood-condition ; and which, as a local manifestation of that disease, is thence denominated idiopathic gangrene. This distinction is noticed more particularly, in connexion with contusion and contused wounds. Of traumatic causes, pressure, or contusion, directly applied, severely although momentarily, as by a squeeze, kills the part immediately. A finger caught in the hinge of a door may thus be squeezed to death. Or, pressure, continued, although less severe, excites gangrenous inflam- mation. In either case, mortification is limited to the part injured. Indirect contusion or concussion, as by a fall, may not be more severe, and is certainly a momentary cause; but it produces gangrene or gan- grenous inflammation; and the mortification will be more extensive, although still co-extensive only Avith the part injured. Pressure or contusion—directly or indirectly—chiefly injures the capillary vessels and smaller arteries ; but traumatic gangrene more fre- quently arises from injury to larger-sized blood-vessels. Considerable haemorrhage takes place, causing gangrene, partly by pressure of the 144 GENERAL PATHOLOGY AND SURGERY. blood extravasated among the textures, partly or principally by cessation of the supply of blood requisite for nutrition. Wounds implicating the larger blood-vessels, compound fracture, and dislocation ; especially operate in this way. Gangrene is not necessarily limited to the immediate and apparent seat of injury; it may extend— e.g., up a whole limb, but still only as high as the cause in operation. Heat, cold, and electricity, require no further consideration as causes of mortification, than that they operate, either by killing outright, or by inducing gangrenous inflammation; cold, hoAvever, not seeming to have the poAver of killing a part at once. A frost-bitten or frozen portion of the body is not irrecoverably dead. (2.) Chemical decomposing agents, on the other hand, mostly operate by killing immediately—decomposing the living tissues with which they come in contact. Such are caustic alkalies, the concentrated mineral acids, and other escharotics. (3.) Animal poisons introduced into the body, are generally less im- mediately killing to the part—i.e., they induce gangrenous inflammation. Bites of venomous serpents represent this class. Internal causes are perversions of the constituent elements of nutri- tion. Blood of a certain "quality," suitable to each part for its nourish- ment, and a certain " quantity " of this blood supplied to and circulated through the part; " an appropriate physical and structural condition of the part itself;" and, some kind of " nervous influence;"—these are the internal conditions, which, when perverted, become internal causes of mortification. (1.) Blood-conditions, by alterations of quality, are eminently constitu- tional causes. Their pathological nature is but little understood; their local manifestations in gangrene, having characteristic appearances, are well known. Some of these blood-conditions were alluded to, in speaking of the varieties of ulcers as depending on constitutional causes. Other such causes more especially give rise to mortification, in various re- markable forms. Thus are produced carbuncle, boil, and the carbuncle of plague ; phlegmonous erysipelas, bloody small-pox, malignant scarla- tina, glanders, ergotism, scorbutic sloughing, the phagedaenic and slough- ing buboes of syphilis. Mortification arising from any blood-disease spreads without limita- tion, as to its extent, (2.) The quantify of blood supplied to and circulated through any part, depends upon and is regulated by the heart's mechanism and action, the state of the blood-vascular system—arteries, veins, and capillaries, and the physical condition of the blood itself, chiefly in respect of its spissi- tude and adhesiveness. These conditions are severally, and collectively, more or less causes of mortification. Of diseases and malformations of the heart, their influence in relation to mortification is impressively illustrated by the following case, which is, I believe, unique. A boy, aged fifteen, came to the Royal Free Hospital, as an out- patient, with bluish-black congestion of the toes of both feet, as high as the instep, and thence shading off in a dusky hue up the legs. The whole surface of the body, was more or less livid, especially the cheeks and lips. The weather was cold, and he had been exposed, with scanty clothing, and had undergone deprivation. But, the circulation was natu- rally feeble, the bluish, almost cyanotic appearance having been noticed ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 145 from birth by those who knew the boy ; his expression Avas anxious and prematurely aged, his manner deliberate and lethargic, and his breathing short and oppressed. After being tAventy-four hours in bed, under the cautious administration of stimulants, brandy and ammonia, with hot bottles to the feet, which were wrapped in cotton-Avool, the general cir- culation had someAvhat returned: but the congestion of the toes had passed into gangrene, sphacelus speedily ensued, and one or two dropped off. I amputated both feet through the tarsal bones; union in part pri- mary, in part by granulation, took place, forming two capital stumps. Recurring attacks of dyspnoea and lividity proved fatal in a month after operation. Post-mortem examination showed that the immediate cause of death Avas acute pericarditis and pleurisy. But the heart was much enlarged, its right half extending outwards to the junction of the ribs and costal cartilages.* (a) Arteries are liable to undergo changes of structure, which are particularly worthy of notice surgically. Ossification or calcareous degeneration of the larger arteries • with fibrous thickening of the smaller ones, accompanied, possibly, with some contraction of the vessels; lead to coagulation of the blood in tubes which have thus become too rigid for the transmission of that fluid, in quantity adequate to meet varying demands. This condition represents the changes of structure concerned in producing " senile " gangrene,— a dry form of mortification, commonly affecting the foot, when the arteries of the leg have undergone these changes. Some slight injury, followed by Ioav inflammation, is usually the immediate or exciting cause in such cases. Traumatic gangrenous inflammation, is in fact, engrafted on the state of the arteries,—as a predisposing condition. Mortification, commencing generally in a part most, distant from the heart, as the ball of the great toe, and thence spreading upwards, gra- dually assumes the appearance of a black slipper on the foot. Arteritis,—inflammation of an artery—is a far less frequent cause; it acts in a similar manner, and may induce gangrene of the same cha- racter, or more dry and horny. Fibrinous coagulum, not formed in the artery where it is found im- pacted, but washed from the left ventricle of the heart and carried thence by the current of blood to that vessel; is another cause of gangrene, perhaps merely an occasional one, but the pathology of this condition has only recently been investigated. An artery thus impacted with a clot, is known as " embolism." Rupture of the internal and middle coats of a large artery, by vio- lence, may induce coagulation; the loose portion folding inwrard across the stream of blood. Mortification is liable to supervene. Aneurism is another cause; partly by interrupting the free flow of arterial blood through the aneurismal artery, and partly, by pressure on adjacent veins, obstructing the return of venous blood. Popliteal aneu- rism will thus induce gangrene, which soon passes into sphacelus, Wound of a main artery acts in two ways, A punctured Avound may be an immediate cause, by loss of blood. A contusion or bruise may lead to sloughing of the vessel, after some days have elapsed; this being attended Avith haemorrhage and false aneurism, followed by mortification. Laceration of the vessel may, in like manner, have the same issue. In * Examination not concluded on going to press, L 146 GENERAL PATHOLOGY AJND S3UKUEKY. either case, the integuments may have escaped injury. Simple fracture, and perhaps, simple dislocations, will thus lead to mortification, occa- sionally. Compound fracture and dislocation, far more frequently. It is highly important to observe the partial extent to which gan- grene is liable to spread, in connexion with all these vascular lesions, as contrasted Avith gangrene arising from any constitutional cause. Un- limited in that case, it is here limited in extent to the source of gangrene, and probably restricted to less than that extent, by the enlargement of branches coming from the artery above the seat of injury, which supply a collateral and compensatory circulation of blood. Thus limited is the gangrene arising from the ossification of arteries or senile gangrene; from arteritis; from embolism ; from partial rupture of an artery; from aneurism; and from wounds of an artery, whether punctured, contused, or lacerated. But, then, the limitation connected with some of these causes,—the point to which gangrene may extend—can scarcely be deter- mined during life. This is the practical ground of distinction between senile gangrene, arising from ossification of the arterial vessels, and traumatic gangrene; and in favour of the latter, the limitation of which can be more definitely predicated. Failing this fore-knowledge, the Surgeon must wait the " line of demarcation," drawn by nature. (b) Veins are less liable to become causes of mortification ; obstruc- tion to the return of venous blood from any part of the body, having a less important relation in this respect, than obstruction to the supply of arterial blood. Phlebitis induces coagulation of blood within the vein or veins in- flamed, and this obstruction is attended with oedematous swelling of the limb or part below. The swelling becoming tense and persistent, is a condition bordering on gangrene. Phlegmasia dolens, in which the iliac and femoral veins, the main venous trunks of the limb are inflamed ; thus perils the leg below. Fibrous obliteration of a venous trunk is another such cause, once in a way, of tense anasarca. Phleboliths or vein-stones, not unfrequently formed within various veins, more particularly the iliac, have a similar tendency. Aneurismal varix and varicose aneurism, resulting from a communica- tion between an artery and a companion vein, as from unskilful venesec- tion at the bend of the elbow ; is attended with venous engorgement, persistent, and increasing, and oedematous swelling of the limb below, threatening gangrene. Prolonged pressure on a large vein, itself in a healthy state, is an extraneous cause of obstruction to the return of venous blood. Tumours, and tight bandaging, may thus, indirectly, have this effect in relation to mortification. The limitation of gangrene is no less characteristic of that which arises from obstruction in the course of a large vein, than from obstruc- tion of a main artery; the gangrene, in either case, extending possibly up to, and probably within, that situation. Thus both classes of causes, those pertaining to the arteries and those pertaining to the veins, concur; and differ from any constitutional cause, in relation to gangrene. The limitation also dependent on some venous causes, like that de- pendent on certain arterial causes, can scarcely he foreseen. Diseased con- ditions of veins are more often perplexing in this respect, as compared ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 147 with any tendency to gangrene of traumatic origin from injury to a large vein. (c) Capillaries.—Compression of these vessels is followed by gan- grene of the part, if thereby deprived of a due supply of blood. Inflammation, therefore, with lymph-production, and compression of the capillary vessels, reacts destructively upon the textures. Moreover, inflammatory products, for the most part, are inherently short-lived. And especially during suppuration, the surrounding textures are dying, disintegrating, and being absorbed to make room for the new product— pus; destruction and production here usually keeping pace. Hence the formation of abscess necessarily pre-supposes the death and absorption of the textures around; and co-extensively with the formation of pus, which now occupies their place. Sometimes, they die faster than absorp- tion can remove them, and then their mortification—as sloughing of the soft textures or a sequestrum of dead bone—becomes plainly visible. Certain conditions predispose to gangrenous inflammation. Blood- poisons are constitutional causes of this kind; as in the production of carbuncle and boil, phlegmonous erysipelas, and the other forms of gan- grenous inflammation, already mentioned in connexion Avith the constitu- tional causes of mortification. Intensity of inflammation has a similar tendency. And lastly, the vascularity of the texture affected; a com- paratively avascular tissue readily becoming gangrenous, and especially if looseness of texture permit the accumulation of serum; as the cellular tissue, in erysipelas, and any texture under the pressure of effusion beneath an unyielding investment, as the tendinous expansion of the occipito-frontalis muscle. (3) Physical and structural conditions of the part in relation to mor- tification generally. Of physical properties; an unyielding fascia or aponeurosis—e.g., the fascia lata, predisposes subjacent textures to gangrene, by pressure in the event of any effusion of blood or serum therein. Looseness of texture also predisposes to this issue, by favouring an interstitial accumulation of blood or serum. Traumatic gangrene is determined, partly by these physical conditions, impeding the nutrition of the part; although mainly, by the insufficient circulation of blood, depriving it of adequate nourish- ment, and by the damage which the textures have directly, or indirectly, sustained by violence. Structural conditions predispose to mortification ; the proportion of blood-vessels having this relation. Both extremes meet—comparatively avascular textures have a tendency to gangrene ; e.g., the liability of cellular texture to slough, from any cause. Highly vascular textures also have a similar tendency, apparently by favouring the intensity of inflammation and effusion; e.g., the skin as compared with fibrous or tendinous textures, which often resist sloughing long after the integument has disappeared in consequence of an extensive burn. Predisposition to gangrene from textural conditions, is most con- spicuous when they are co-operative causes. Cellular texture for example, being comparatively avascular, as well as liable by its looseness to become the seat of interstitial effusions, most readily sloughs. Causes of Ulceration.—By some variation in the degree of any cause of Mortification, this process of mass-disintegration subsides into that of molecular disintegration. Ulceration is mortification by small instal- ments. Consequently, similar conditions of texture predispose thereto. Thus, Avith regard to vascularity ; the less vascular textures are prone to l2 148 GENERAL PATHOLOGY AND SURGERY. ulcerate, as well as mortify,—e.g., cellular-texture, and cicatrix-tissue; in this respect agreeing with the liability of the highly vascular skin, and mucous membrane, to inflammation and thence to ulceration. The comparative liability of different textures to ulceration and mortification, is well shown in the natural process by Avhich a dead limb is gradually separated from the living tissues ; they detaching themselves from the dead. All, excepting the cellular texture and tendons, are severed by ulceration forming a fissure, which is progressively incisive down to and through the bone. The dead skin, vessels, muscular tissue, and bone are severally detached evenly, by ulceration ; but the cellular texture and tendons die for some distance upwards within the stump, and are detached irregularly, by sloughing. ^ (4) Nervous influence, of some kind, plays an important part in mortification and ulceration. For example ; injury to the spine has been followed within twenty-four hours by mortification of the ankle ; and the tendency to ulceration in such a case, or of the cornea in connexion with facial paralysis, is equally remarkable. Considering the whole etiology of mortification and ulceration practi- cally, the most important general fact is the co-operation, usually, of two or more causes, in either mode of death; whereby it is difficult to deter- mine the share due to each internal condition, more especially in con- junction with the operation of external circumstances, such as moisture, temperature, etc. The Fever of Mortification.—Coincident with mortification, as the local disorganization, the constitutional disorder at once commences. Its phenomena or symptoms, are generally more insidious, but not unlike those of Pyaemia, though differing in degree. A wild apprehensive look, with great restlessness, are conspicuous ; the features and manner at length become somewhat composed, and the face assumes a pallid hue. In some cases, the tunicae conjunctivae, and the skin over the whole body, acquire a peculiar yelloAv colour. Utter prostration of mind and mus- cular power gradually supervenes, and a quivering subsultus tendinum steals over the patient. The pulse is now very feeble, rapid, and irregu- lar, feeling like a fine rough wire drawn under the finger, and perhaps scarcely to be distinguished from the vibrating subsultus of the adjoining tendons. The secretions are soon perverted. The skin, at first hot and dry, is afterwards bathed with a cold, clammy sAveat. The urine, foetid and scanty, may be suppressed. A broAvn, rough, dry tongue with black sordes encrusting the lips, are accompanied with nausea and a putrid diarrhoea. The powers of organic and of animal life failing, involuntary excito-motions prevail; spasms and convulsions shake the moribund body, while coma ends in death. Or, the mortification ceases to spread. The reddish brown tint of the skin bordering the dead part, and which has hitherto spread in advance, gets brighter and more circumscribed. A white raised line—the " line of demarcation"—forms in the living skin immediately adjoining the dead ; it melts into a groove by ulceration, which extending deeper and deeper, as a fissure, successively passes through tissue after tissue, and at length converging, thus completely detaches the Avhole of the dead part. Pending this course of severation from the living organism, adhesive inflammation precedes the line of ulceration, and, corresponding to it in length and depth, seals the blood-vessels ; thus effectually excluding any further communication with the dead tissues and preventing their absorp- ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 149 tion for the time to come. The typhoid fever immediately begins to subside, and ultimately ceases. In exchange, some degree of " inflam- matory fever " accompanies the concurrent process of ulcerative separation and reparative adhesion. Such is a descriptive outline of the origin, course, and termination, fatal or favourable, of the constitutional disorder proceeding from morti- fication. Arising with spreading gangrene, it ceases when the dead part is detached from the living body. Respecting the obvious dependence of this fever on mortification; these two general facts, taken conjointly, seem to warrant the conclusion, that absorption of the dead tissues as the connecting link is the immediate cause of the fever. The presence of gas, as decomposition supervenes on sphacelus, is probably a co-opera- tive cause, subsequently, by its direct influence on the nervous system. Absorption of dead matter primarily, nervous sympathy secondarily, and ultimately both together, induce and maintain the typhoid fever which proceeds from mortification. Treatment of Mortification. Taking a comprehensive retrospect of the pathology and etiology of (ulceration and) mortification, the Indications of Treatment are four:— (1) To remove the cause or causes, in operation, and thus arrest the progress of death. (2) To remove the dead part—e.g., a slough, a sequestrum, a limb ; and the proper time for such surgical interference. (3) To solicit the natural separation of the dead part, with reparative closure of the blood-vessels, simultaneously and co-extensively; and the reparative process of granulation and cicatrization, subsequently. (4) To control the constitutional disorder, consequent on morti- fication. (1) The causes of Mortification are, as we have seen, external and internal. Of External causes; some only are persistent in their operation, and therefore practically important in that respect. Mechanical violence, heat, cold, electricity, as lightning, and chemical decomposing agents; are ex- ternal causes, the operation of which is all but momentary. Animal poisons introduced into any part of the body, are persistent causes, so long, at least, as any such poisonous matter continues operative. Hence the importance of their early removal. This may be accomplished in various Avays. The application of a cupping-glass is calculated to withdraw the poison, and without sacrificing the part. Free excision of the part itself, may remove the poison, but Avith a proportionate mutilation. Neutra- lization of the poison by caustics, or the actual cautery, with destruction of more or less of the textures, in situ ; is a resource of an intermediate character. A bandage applied with some tightness above the part affected, in the case of a limb, may prevent poisonous matter from entering the general circulation. Of these four appliances, cupping is the most practicable and ef- fectual. Of Internal causes ; some only are removable by any known remedial measures. 150 GENERAL PATHOLOGY AND SURGERY. Blood-conditions, as pertaining to some altered quality of the blood in circulation, are thus, for the most part, beyond control. Such are the blood-diseases of carbuncle and boil, erysipelas, small-pox, malignant scarlatina, glanders, ergotism, scurvy, and constitutional syphilis ; the two last more especially inducing ulceration. Conditions pertaining to a deficient quantity of blood as causes of mortification, are more amenable to treatment. (a) Arteries are liable to six such causative conditions, three -of which may be effectually overcome—Arteritis, Aneurism, and Wound of a main artery. The first-named disease should be treated according to the rules laid down for inflammation in general; the second and third conditions are fully considered with regard to treatment, under their respective headings. (b) Veins are liable to five analogous causative conditions; three of which are remediable—Phlebitis, Aneurismal Varix and Varicose Aneurism, and prolonged Pressure on a main vein, as by a tumour or tight bandaging. The treatment of these conditions will be found in their proper places, (c) Capillary vessels in relation to mortification, are commonly asso- ciated with the pathology of Inflammation. Defective capillary circula- tion, as connected with a comparatively avascular condition of structure, is another internal cause; and intensity of inflammatory hyperaemia and effusion, as dependent on a highly vascular condition, is a third such cause. The one suggests stimulating embrocations, friction, and other similar appliances, to promote the deficient circulation—e.g., in the treat- ment of bed-sore3 resulting from pressure which reduces the skin to a virtually avascular condition. The other condition suggests local deple- tion, and other similar measures, as for inflammation. Ulceration, resulting from causes precisely analogous to those of Mor- tification, will require similar measures for their removal. Thus, for example, chilblains, occurring as they do in persons of weak circulation, are prone to ulcerate, and are best treated by spirit lotions and other stimulating applications. Lastly, defective nervous influence, of some kind, has an important causative relation to Mortification and Ulceration ; but the removal of this internal cause—the restoration of such influence—may be very difficult. If the occasion of defective nervous influence be local and mechanical, as pressure from a tumour on a nerve, above the seat of sloughing; its removal will be curative. But in some such cases, the source of pressure may not be accessible ; and in others, persistent or recurring, thus frustrating the treatment. [P. p. 566.] In cases not referable to any mechanical cause, strychnine administered in small doses,—the sixteenth or twelfth of a grain, and continued until some slight tetanic twitchings of the muscles ensue, may have some efficacy in restoring nervous influence; and galvanism in like manner. (2) Removal of the dead part by operation, and the proper time for such surgical interference. As the immediate cause of the constitutional disorder, removal of any mortified part,—a slough, sequestrum, or a limb, is an indication of treat- ment obviously necessary. But the earliest opportunity for fulfilling this indication, with due regard to the non-recurrence of gangrene in the part adjoining, may be a question for the Surgeon's consideration. The removal of a loose slough of soft textures or a sequestrum of ULCERATION AND ULCERS, GANGRENE AND MORTIFICATION. 151 bone, cannot admit of any such doubt; for there and then, mortification has become defined. Amputation of any part, as a limb, is a question respecting the spread- ing of gangrene, and the probability of its recurrence in the stump. The consideration which partly determines this question is, the constitutional or the local origin of the gangrene. In the former case, spreading without limitation, as to its extent, amputation must be postponed until the " line of demarcation" has formed; in the latter, limited in its extent to the source of gangrene, and probably restricted to within that boundary,—by the establishment of a collateral circulation, from above to beloAV; amputation may be performed prior to the forma- tion of the line of demarcation. But in certain of these naturally limited gangrenes, the limitation cannot be foretold, simply because the exact situation of the causative condition cannot be diagnosed. Of arterial conditions; such are ossifi- cation of a main artery or arteries, leading to senile gangrene ; arteritis, indefinite in a lesser degree, as to its extent; embolism; and partial rupture of an artery without any external wound. Of venous conditions; such also are fibrous obliteration of a large vein; phleboliths or vein- stones impacted ; and phlebitis, indefinite as to its extent. Hence, in all these cases, arterial and venous—the treatment appropriate for the par- ticular causative condition having failed—amputation must be deferred until such time as nature has indicated by the formation of the line of demarcation, that limitation Avhich cannot be foreseen. The venous con- ditions referred to, seldom, if ever, necessitate amputation. On the other hand, the line of demarcation can be foretold, in other cases of definitely local origin. Such are aneurisms—spontaneous and traumatic, and wounds of a main artery; aneurismal varix, and varicose aneurism; and any occasion of prolonged pressure on a large vein. Hence, in all these cases,—arterial or venous,—the treatment appropriate for the particular causative condition having failed—amputation may be resorted to before the formation of the line of demarcation has indicated the actual extent to which the gangrene will spread. Generally speaking, the rule for amputation may be thus stated, in all cases of local origin ; idiopathic gangrene, however caused, suggests the postponement of ampu- tation until the limitation of gangrene is declared by Nature; whereas, traumatic gangrene, however caused, suggests amputation more imme- diately ; the anticipation of Nature by Surgical Art, then being justifiable. Two exceptions are urged by Erichsen—namely, gangrene from frost- bite, and that from severe burns. In these injuries, he considers it better to wait for the formation of the line of separation, and then to fashion the stump through or just above it, as the circumstances of the case require. In Spreading traumatic gangrene, the question of amputation should be determined rather by the consideration that a constitutional cause is in operation. Postponement of amputation, therefore, pending the forma- tion of the natural line of demarcation, is the rule of treatment. (3) Solicitation of the natural separation of the dead part, with reparative closure of the blood-vessels, simultaneously and co-extensively, and the reparative process of granulation and cicatrization, subsequently. Constitutional gangrene, and gangrene arising from local conditions the exact situation of which cannot be diagnosed; may have compelled the postponement of amputation, pending the natural limitation of gan- 152 GENERAL PATHOLOGY AND SURGERY. grene; but Surgical Art should solicit this limitation, and thus also, if possible restrict the extent to which the gangrene might otherwise have spread. By maintaining the temperature of the part, not yet mortified, the local circulation may become diffused sufficiently to sustain its vitality ; whereby the line of demarcation betAveen the living and the dead portions will be declared. Hence, the preventive value of cotton-wool, with which material the limb should be deeply enveloped. This padding need not be reapplied for some days, the gangrenous part being covered with lint soaked in a chlorinated, carbolic, or other antiseptic lotion. In senile gangrene, the line of demarcation having formed, and separa- tion of the dead part, slowly taking place; reparative closure of the blood- vessels will be promoted by a light poultice or epithem of moist spongio- piline, to encourage adhesive inflammation. When the soft textures are thus safely detached, the bone may be sawn through, and the otherwise natural amputation completed by this amount of surgical interference. Granulation and cicatrization supervene as in the healing of a healthy ulcer, although perhaps more slowly than usual. Simple water dressing or some gently stimulating lotion, will therefore generally prove sufficient in the way of topical treatment. Balsam of Peru, pure or diluted, with an equal part of yolk of egg, is highly recommended as an application in these cases. Remembering the persistent cause of gangrene—namely, ossification of the arteries; exposure to cold must ever be avoided, and the circulation in the legs cherished by the patient wearing thick woollen socks, flannel drawers, and other such warm clothing. (4) Constitutional Treatment.—Prior to closure of the vessels, the con- stitutional disorder consequent on gangrene—the typhoidal fever, requires supporting measures ; an easily assimilated diet, comprising propor- tionately more animal food, malt liquor, and alcoholic stimulants, will prove most beneficial. Of medicinal stimulants and tonics ; the sesqui- carbonate of ammonia and chlorate of potash, with cinchona bark or cascarilla, form a combination, which is, I think, more lauded in the books, than suggested by pathology or sanctioned by experience. Opium is, generally, a remedy of great value, apparently by subduing the ner- vous excitement and promoting the capillary circulation, thus aiding the process of separation. It should be administered in small but repeated doses, to the amount of from two to four grains in the twenty-four hours, and increased as the system is brought under its influence ; but opium is contra-indicated or must be discontinued, whenever it disturbs the diges- tive organs or occasions headache. Infiammatwy fever, in some degree, accompanies occlusion of the vessels during the separation of the gangrenous part; opium may there- fore still be continued to suppress nervous excitement and the heart's action, while it sustains adhesive inflammation. Any topical measures to regulate the inflammation are unnecessary, or would be absolutely provocative of gangrene unless applied with the most tentative caution. This due consideration and balance of constitutional and local treat- ment, with watchful supervision of the remedial agents employed, con- stitutes the scientific practice of medical and surgical art as responsive to the ever-changing conditions of pathology—the body in disease. 153 DISEASES OF THE BLOOD. CHAPTER V. SCROFULA. Scrofula is a constitutional disease of " blood-origin" because possessing the family features of this class of diseases. In tracing these family features throughout the various local manifestations of scrofula, I shall not include those of an allied blood-disease—Tuberculosis ; for these diseases do not appear to be identical, as some pathologists have main- tained, and even still allege. I endorse the view held by Mr. Paget, that this is their relation—" the scrofulous constitution implies a peculiar liability to the tuberculous diseases, and that they often co-exist." But "their differences are evident, in that many instances of scrofula (in the ordinary meaning of the word) exist with intense and long-continued disease, but without tuberculous deposit; that as many instances of tuberculous disease may be found without any of the non-tuberculous affections of scrofula; that, as Mr. Simon has proved, while diseases of ' defective power,' may be experimentally produced in animals by insufficient nutriment and other debilitating influences, tuber- culous diseases are hardly artificially producible ; and that nearly all other diseases may co-exist with the scrofulous, but some are nearly in- compatible with the tuberculous."* General Symptoms.—Scrofula—thus distinguished from tuberculosis— exhibits itself locally by " mal-nutrition and chronic inflammation." This inflammation is scarcely expressed by pain or heat, or redness, but rather by swelling, more or less considerable and doughy, slowly enlarging, and tending to suppuration; yet scrofulous suppuration is unwilling, so to speak, and the pus a mixture of curd and serum. Should a scrofulous abscess point, the skin thins, but gradually, and assumes a pnrplish tint; an irregular rent follows after some time, and the flaky matter rolls out. Perhaps this aperture gets blocked up and imperfectly closed; the matter reaccumulating, again to be discharged, and so on from time to time. Or the aperture may remain free, with puffy everted edges of a purplish colour, and the discharge continue—now thick, now thin. The scrofulous ulcer, which eventually results is equally indolent. It persists, Avith a thin, livid, undermined margin, large, pale, flabby granu- lations and a gleety discharge ; although sometimes pretending to heal, by this discharge crusting over its surface. Should cicatrization ensue, the scrofulous cicatrix appears drawn, puckered, and incomplete. Small bridges form across the ulcer, underneath which a probe can be passed readily, in and out, here and there. Nature does but " skin and film the ulcerous spot." Special Forms.—Scrofula is essentially a " pervading" disease. It blossoms and bears fruit chiefly in the absorbent glands, in the skin and cellular texture, mucous membranes, bones and joints, eyes, salivary * Surg. Pathology, 1853, vol. ii. 154 GENERAL PATHOLOGY AND SURGERY. glands, tonsils, ears, breasts, and in the testicles. Then, again, in some cases, various parts are simultaneously affected, in others consecutively; the scrofulous affection " migrating" from one texture or part to another texture or part. But their order of priority cannot be stated Avith accu- racy. In some textures, the scrofulous affection is more pronounced than in others. Absorbent glands, so called, appear to invite the deposit of scrofulous matter. At first soft and fleshy, these glands enlarge and harden; " portions of each gland are observed to have altogether lost their flesh colour, and acquired a degree of transparency, and a texture approaching to that of cartilage."* At length, a soft, white, or yellowish, curd-like substance is deposited. Glandular tumours, thus formed about the neck and groin, sometimes attain an enormous size; in the latter situation, being perhaps half as large as the head of a new-born child. An en- larged scrofulous gland is not necessarily impervious—at least, mercury can be injected in many instances.f Scrofulous glands are remarkably indolent, but eventually they soften and discharge the characteristic pus, —flaky and ichorous, perhaps cretaceous matter; or they remain as soft and spongy tumours, beneath a thin, silky cuticle, which frequently breaks and oozes; or they waste, and are at length represented only by " a few bands of condensed cellular tissue attached to the cicatrized in- tegument."! Absorbent vessels are said to be rarely the receptacles of scrofulous matter, but there are such instances on record. Chronic enlargement with suppuration of the lymphatic glands is one of the earliest characteristic manifestations of scrofula. In childhood, therefore, these glands may be found as just described, in various stages of scrofulous inflammation and suppuration. Yet this is a rare event in children under tAvo years of age. Thomson witnessed it earlier than this, and Cullen mentions a case in which the disease broke out at the very early period of three months. Taking the other extreme, Thomson found the mesenteric glands affected with scrofulous inflammation in per- sons of very advanced age. In various parts, also, of the body, the lymphatic glands may become scrofulous. Those in the neck—glandules concatenate—are perhaps most frequently affected; and, according to Thomson's experience, scrofulous enlargement, &c, of these glands is more commonly symptomatic of irri- tation in neighbouring parts than an idiopathic condition,—provided, in either case, the scrofulous diathesis be present. This enlargement of the cervical glands is apt to arise from slight and transitory injuries and affec- tions of the hairy scalp, ears, eyes, nose, and more particularly from slight and temporary affections of the teeth, gums, and other parts within the mouth. Decay of the first teeth is often the immediate cause of scro- fulous glandular swellings in the neck, but their eruption, seldom or never.§ The axillary and crural glands are less frequently affected than those of the neck ; and Thomson believes that their enlargement also is sympto- matic, in this case, by absorption of scrofulous matter from parts more or less remote. This authority was acquainted with but few instances of idiopathic scrofulous swellings of the glands in the groin or armpit. The mesenteric glands are very liable to undergo scrofulous inflammation, * Med.-Chir. Trans. Edin., vol. i. p. 683. (Abercrombie.) t Cyclop. Practical Medicine, 1834, vol. iii. p. 705. X Ibid. § Lectures on Inflammation, p. 157. SCROFULA. 1 * F" loo constituting that formidable disease, tabes mesenterica, by arresting the absorption and passage of chyle through these glands, and thus inevitably depriving the whole body of its nutriment. A tumid abdomen, with pro- gressive emaciation, begets suspicion of this disease; while detection of the mesenteric mass, by palpation and percussion, will go far towards confirming our diagnosis. Besides, hoAvever, the physical signs and their interpretation, which Pathology supplies, there are, as regards all diseases, with feAv exceptions, other circumstances whose evidence should be weighed. We look for the concurrence of some other expressions of the scrofulous diathesis. Age, also, should be taken into account; but, in this respect, Thomson found the mesenteric glands affected in children two years old, in persons between twenty and thirty, and in those who had passed their sixtieth year. The cellular texture is peculiarly liable to exhibit scrofulous swellings, bordering on suppuration or actual collections of matter. In the subcutaneous cellular tissue, small nodules are apt to form closely resembling scrofulous glands in appearance. Of this kind are the swel- lings described by Thomson as being " soft and puffy," and having little or no disposition to suppurate. " They often appear very suddenly; and from the absence of pain and discoloration, they may exist a long time without being perceived. They are usually of an oval figure, and seem to be produced by the effusion of a fluid into the interstices of the cellu- lar texture; they are very variable in their size, being one day more prominent and tense, and the next more flaccid." Subcutaneous abscesses may form, and are usually numerous. When an absorbent gland sup- purates and bursts, a fistulous sore is the result; but abscess in the sub- cutaneous cellular texture commonly terminates in an open scrofulous ulcer. In the sheaths of muscles, large chronic abscesses sometimes gather insidiously, containing the pus Avhich characterizes scrofulous suppura- tion. The skin is more than liable—it is prone—to scrofulous eruptions and ulceration. Its wrinkled seams and puckered scars are familiar to common observation. And these vestiges are not unfrequently " symme- trically " disposed on either side of the body. Indeed, this symmetrical distribution is more common in scrofulous affections of the skin, or at least, is more apparent in that texture, than in those of other textures. An instance of remarkably symmetrical scrofulous scars on the neck and fore part of the chest, occurred in a patient of mine at the Royal Free Hospital. In the middle line, a vertical scar extended dowmvards to the sterno-clavicular articulation, terminating in a kind of root, and upwards to the os hyoides. From thence a branch scar passed upwards and back- Avards to the an_le of the jaw, on either side; and from this again, on either side, another seam extended upwards to the mastoid process, and downwards on the sterno-mastoid muscle. Either axilla Avas the seat of an horizontal seam, which discharged a small quantity of scrofulous matter. According to the special experience of Erasmus Wilson,* cuta- neous scrofula is presented in two conditions—that of tubercles, and that of ulcers. Scrofulous tubercles are small, purplish or livid, indolent tumours. They soften internally and discharge an imperfect pus, remain open or fistulous for a long time, and on disappearing, frequently leave * Diseases of the Sinn, 1S57. 156 GENERAL PATHOLOGY AND SURGERY. hard knots in the skin. They appear on the neck and face, and near ulcers resulting from inflammation of the absorbent glands. When such tubercles have partially discharged their contents, a crust of inspissated matter forms, which being rubbed off occasionally, exhibits an open sore, with an ichorous discharge, and no disposition to heal. Eventually an ugly cicatrix or scar marks the site of these sores. Usually but one scrofulous tubercle arises; sometimes a group of three or four close together, which may have a circular arrangement, enclosing an area of thin, shining, livid or purplish skin. Rings of this kind occur chiefly on the back of the hands and feet. They are very intractable. The characters of the scrofulous ulcer need not be repeated. An irregular, livid, and puckered scar is its remnant. Such cicatrices are seen mostly in the neck, near enlarged glands, and in the neighbourhood of joints. Inflammation of the matrix of one or other of the nails is not uncom- mon, more particularly in young persons having the scrofulous diathesis. Scrofulo-derma ungueale, so named, begins by inflammation of the skin immediately around the edges of the nail about to be affected ; then fol- lows considerable swelling, with vivid redness of the end of the finger, extending even to the bone, and presenting the appearance of a clubbed finger. The nail is shed, disclosing an angry raw surface, upon which, from time to time, there reappears a rugged, ill-formed and imperfect nail. Fungous granulations and unhealthy pus continue for perhaps many months. Other cutaneous manifestations of scrofula are noticed by some writers. Porrigo favosa, larvalis, and furfurans; eczema impetiginodes and ru- brum, in their chronic forms ; and that variety of lupus which appears as small, red, button-like, indolent tubercles, chiefly on the lips and nose, occasionally on the genitals. These tubercles excoriate and run into ero- ding ulcers, with pale, shining, spongy granulations and encrusted margins ; or perhaps this work of destruction is concealed by a thick incrustation, which every now and then drops off, exposing its subjacent ravages. The osseous system and the joints seem to invite scrofulous inflamma- tion—in this respect contrasting with the indisposition evinced by these structures towards the syphilitic poison, unless reinforced by mercury. The bones and joints, then, are conspicuous in the history of scrofulous manifestations. And both may be coupled together, because it is near to joints that the bones are commonly affected. In the extremities of long bones, or in the bones of the carpus and tarsus, their cancellated portion, chiefly, undergoes a series of structural changes, which, with the symptoms, or rather, signs by which they are denoted, will be traced consecutively in describing Diseases of the Bones. I allude to scrofu- lous caries. Sometimes this species of mal-nutrition runs its course within the shaft of a long bone, but generally speaking, as I have said, in the neighbourhood of joints. The latter are secondarily invaded, caries so placed then being denominated "scrofulous disease of the joints." An inflammation of the synovial membrane, known as " scrofulous syno- vitis," was formerly regarded as a primary and distinct disease. More than probably, however, it arises by extension of the destructive pro- cess from the cancellated bone. In the career of scrofula, mucous membranes are not exempt from harm, particularly if its blood-associate, tuberculosis, be considered an ally. The eyes, ears, nose, upper lip, tongue, tonsils, salivary glands, and SCROFULA. 157 larynx, severally exhibit scrofulous inflammation; yet this is not alto- gether limited to the mucous membrane in connexion with these parts. Scrofulous ophthalmia is a variety of conjunctivitis, characterized by great intolerance of light; so that the child (for this affection occurs mostly in young subjects) seeks a dark room, or buries its head in the bed-clothes, and screws its brows together with screaming agony on any attempt being made to examine the eyeball. From habitually endeavour- ing to exclude the light, the corrugator and orbicularis muscles become hypertrophied, eventually giving a remarkable heaviness of expression. When the eyelids are separated, a copious Aoav of tears trickles down the cheek, excoriating the face. The eyeball is now involuntarily upturned to avoid the light, a patchy redness is observable on the conjunctiva, and vesicles or pustules are seen here and there at the margin or on the surface of the cornea. These pustules burst and expose small ulcers. Fre- quently an interstitial deposit overshadows the whole cornea, which thus becomes thickened and opake (pannus), projecting also, so that the eye- lids cannot be closed. This is one destructive sequel, and should ulcera- tion of the cornea not terminate comparatively favourably—in specks of opacity, perforation of the anterior chamber is inevitable, the aqueous humour is discharged with prolapsus of the iris, and the eye collapses. Fretting ulceration of the Meibomian glands, attacking the margin more especially of the eyelids, and known as ophthalmia tarsi, is a fre- quent concomitant of scrofulous ophthalmia; or this diseased condition extends to the iris, giving rise to scrofulous iritis. But there is nothing characteristic about this variety of iritis, taken per se ; and indeed it is only as one of a series of local manifestations that we venture to desig- nate it " scrofulous" iritis, and refer the Avhole series to one and the same constitutional cause in operation. The organs of hearing do not escape. Chronic suppuration perforates the tympanum ; the ossicula crumble, loosen, and are washed out by the discharge. The nose assuredly enjoys no immunity. Habitual swelling, ulcera- tion, and foetid discharge from the pittiitary membrane—ozaena—may or may not be accompanied with caries and discharge of portions of the spongy bones. The upper lip is commonly tumid, protuberant, and chapped. Fis- sures also and ulcerated spots are seen on the tongue. Nodules, more- over, superficially imbedded in the substance of this organ are said to arise in most instances, and to present the following characters. They vary in size from a small shot to that of a horsebean ; are painless, unless subjected to firm pressure, which occasions a pricking sensation. The superimposed mucous membrane reddens, soon breaks in the centre, and forms an ulcer, which spreads and destroys by sloughing erosion; ac- companied with much pain, profuse salivation, furred tongue, and foetid breath. If cicatrization ensue, hardness still remains; fresh nodules also form in other parts of the tongue.* Chronic and considerable enlargement of the tonsils, with perhaps indolent ulceration, is another outbreak of the scrofulous diathesis; so likewise is SAvelling of the sub-lingual, sub-maxillary, and occasionally the parotid salivary glands; but these affections alike owe their signifi- cance to the invariable co-existence of other local diseases of more un- equivocally scrofulous origin. * Cyclop. Practical Medicine, 1834, vol. iii., art. Scrofula. 158 GENERAL PATHOLOGY AND SURGERY. This remark holds good of another inflammation of mucous mem- brane, and the last which I shall notice in connexion with scrofula. Chronic laryngitis may be due to this constitutional cause. The vocal cords become thickened ; the voice therefore is hoarse or squeaking, and the breathing embarrassed; a tickling cough from time to time ejects a slimy, not frothy, expectoration, streaked with blood perhaps; or the sputa are muco-purulent. In either case the breathing is relieved by this expectoration ; but eventually ulceration of the rima glottidis renders its closure imperfect, the act of coughing incomplete, and expectoration therefore difficult; respiration is proportionately more embarrassed. Should ulceration of the epiglottis supervene, there will be a correspond- ing difficulty of deglutition. I need not enlarge this description ; suf- ficient for my purpose to identify chronic laryngitis, while the invariable co-existence of other local affections of more exclusively scrofulous origin associates this disease with that series of local manifestations which pro- ceed from the scrofulous blood-crasis. In like manner I have to notice a certain mammary tumour, first described by Sir A. Cooper.* "In young women," says this author, " who have enlargement of the cervical glands, I have sometimes, though rarely, seen tumours of a scrofulous nature form in their bosoms, con- fined in most cases to a single tumour in one breast; but in one case two existed in one breast, and one in the other. They are entirely un- attended with pain, are distinctly circumscribed, are very smooth on their surfaces, and scarcely tender to pressure. They are very indolent, but vary with the state of the constitution, diminishing as it improves, and increasing as the general health is deteriorating. They can only be distinguished from simple chronic inflammation of the breast, by the absence of tenderness, and by the existence of other diseases of a similar kind in the absorbent glands of other parts of the body. They produce no dangerous effects, and do not degenerate into malignancy." Lastly, a peculiar enlargement of the testicle, or rather, of the epidi- dymis, is worthy of special notice among the local manifestations of scro- fula ; and it particularly exhibits the usual characters of stealthiness and slow development. A small nodule, consisting of yellow friable matter deposited within the tubules or ducts, appears generally at one end of the epididymis; little pain or tenderness attends this structural change, and it may progress without complaint. Another and another such nodule forms on the surface of the testis, but generally connected Avith the epidi- dymis, which becomes beset with three or four small tumours. Thus the testicle itself feels enlarged and irregular at an early stage of this disease. It has been statedf that scrofulous matter is also deposited within the body of the testis, in the form of pearly or greyish bodies, of the shape and size of millet-seeds—i e., grey granular tubercles, which I suppose this description denotes. That these tubercles have a linear arrangement, like strung beads, less abundant and less regular in the anterior part of the organ than towards the rete-testis, where they are closely set, and sometimes confluent; and that they undergo transformation into a yellow friable cheesy substance, which at a later period softens, and is often broken up into a curdy purulent fluid, the gland-structure being absorbed to give place to this tuberculous matter. But, if tubercles are depo- sited within the testicle itself, this structural change signifies little in * Diseases of the Breast, 1829, chap. viii. t Diseases of the Testis, Curling, 1856. SCROFULA. 159 reference to an early and exact diagnosis, for the " testis is often masked by small local effusions of fluid in the tunica vaginalis," the surfaces of Avhich are partially adherent. Now, the epididymis may remain nodose for many months ; the no- dules quiescent, or enlarging very slowly, and becoming painful. At length one declares itself more than the rest, attaches itself to the skin, which then assumes a purplish discoloration, ulcerates, and discharges a curdy purulent matter—the substance of the nodule. Other nodules undergo successively this process of disintegration, softening, and evacua- tion ; but, unlike healthy abscesses, they do not heal. Fistulous openings obstinately continue to exude a mixed discharge—now curdy, now serous, noAv seminal; and in this advanced stage of the disease, destruction of more or less of the gland substance is inevitable. According to Sir B. Brodie's observations,* occasionally one testis is completely disorganized; more frequently the organ is only partially destroyed, and a considerable portion of the glandular structure remains unimpaired. Sometimes the disease is confined to one testicle; sometimes both are similarly involved. By this process of disorganization and protracted discharge the testicle is drilled and worm-eaten, as it were ; so that eventually the organ col- lapses and shrivels up—a fragment only of its former self. There is seldom, therefore, any protrusion of gland-substance through the fistulous scrotum; on the contrary, in a favourable case the apertures gradually become inverted and depressed,—leaving, after the lapse of time, a puckered cicatrix, adherent to the remaining portion of the gland, as a lasting record of all this mischief. Blood-origin.—In concluding this summary of many local diseases, which, possessing the same general characters, are fairly associated under the name of Scrofula, it is impossible to overlook at least tAvo general facts that indicate their blood-origin. These diseases are perversions of nutrition in " many" textures and organs simultaneously; they " mi- grate" from one locality to another, and they are occasionally symmetrical. So, therefore, scrofula is, properly speaking, a blood-disease, and the diseases alluded to are local manifestations of a constitutional cause in operation. Blood-pathology.—Nothing definite is known respecting the composi- tion of the blood in scrofula. The blood is said to be rich in its amount of fibrin, but thin, of inferior plastic quality, and poor in its proportion of red corpuscles ;—such is the result of analysis by Andral and Gavarret: that the " solids of the serum " are increased, and the " blood-globules " diminished, was the result of Dr. Glover's analyses;! and so on I might enumerate the conclusions of many other distinguished chemists. Causes.—Temperament.—Certain bodily organizations evince a ten- dency to scrofula, and beget a suspicion that it will declare itself in some way, sooner or later. Individuals thus constituted are ever verging on this morbid condition, with threatenings of its outbreak here or there; but it must be confessed that no one temperament alone pos- sesses the scrofulous character. It is the tendency of those whose circulation is habitually Aveak—are leucophlegniatic—who have flabby muscles, a dull muddy complexion, large heads, pigeon breasts, tumid bellies, and large joints ; but then the strumous tendency is manifested in those persons also Avho, Avith a more active circulation, are rather of * London Med. Gazette, vol. iii. p. 377. t Pathology and Treatment of Scrofula. Fothergillian Prize Essay, 1846, p. 115. 160 GENERAL PATHOLOGY AND SURGERY. the sanguine temperament, have firmer muscles, a clear, transparent, ruddy complexion, Avhich readily assumes a purple or livid hue by ex- posure to cold. The circulation, although active, is susceptible. Chil- blains, therefore, not uncommonly occur in children of this temperament; while their yellow or reddish hair, large lustrous blue eyes, crimson- patched cheeks, and pouting upper lip, are associated with that lively, impulsive, affectionate, and precocious disposition which so often raises hopeful expectations, never to be realized. In contrast, however, with this organization and with these mental endowments, the same strumous tendency may be evinced in the highest degree by those who, without any marked character of circulation, are habitually subject to biliousness. In such persons the liver seems to be their weak point. Sluggish, yet enduring power is theirs also ; and hair approaching black in colour, a dark olive or yellowish complexion, and dry skin, are aptly associated with a gloomy, often resolute, and reflective disposition. Theirs is the melancholic temperament. These are the chief signs of the scrofulous diathesis, although it may appear also in persons of the nervous temperament; and, indeed, the same tendency can be induced in those who are congenitally most indisposed to it when sub- jected to circumstances favourable to its deA-elopment. Hygienic Conditions.—Whatever impairs the nutritive qualities of the blood and its circulation may produce scrofula; therefore, deficient or defective food, indoor-life, insufficient ventilation, want of cleanliness and excretion, poor clothing, cold, damp, and even dark localities, with other circumstances of similar character, are the nurseries and nurses of this blood-disease. At the same time, individual predisposition, as usual, plays its part; for among a family of children in precisely the name hygienic circumstances, one becomes scrofulous, while the rest escape. Treatment.—Preventive measures are far more efficacious than remedial treatment. They consist in the anticipation or timely removal of the predisposing hygienic conditions just adverted to; any inborn predis- position by temperament being beyond prevention. Due attention to food is primarily important. In the absence of more precise knowledge respecting the blood-condition in scrofula, it is impossible to direct and regulate the diet chemically. Experience, however, suggests a light nutri- tive diet, and not to overload the stomach by a heavy meal. Stimulants may be necessary to assist digestion, but they should be indulged in sparingly. The pampered scrofulous child of affluent parents is as badly off as the ill-fed child of the poorest. The bowels, which are very apt to be costive, or at least irregular in their action, will require the assistance of gentle aperients, such as rhubarb or the confection of senna. Not less important is daily exercise in pure air, and ablution not only to cleanse the skin, but to invigorate the circulation and promote excretion. Hence, sea-bathing may prove very beneficial. Friction Avith the horse-hair gloves and belt, or a rough toAvel, and warm clothing, with flannel next the skin, are likewise salutary. But, a warm, dry, light, locality for habita- tion, in a well-ventilated and well-drained dwelling, constitute the hygienic surroundings which are most preventive of scrofula. The latter, especially, is a hard prescription for the poor to carry out. Among, however, the many blessings bestowed on them in this vast metropolis, by the im- perishable philanthropy of Mr. George Peabody, a yearly decreasing pre- disposition to scrofula, will perhaps be the greatest boon. Curative treatment implies the same continued attention to the removal SCROFULA. 161 of any causes provocative of this disease. The hygienic conditions of diet, exercise, air, ablution for cleanliness and invigoration, clothing, and climatic influence, are still of paramount importance. But certain medicinal agents, principally iron, iodide of potassium, bark, and cod-liver oil, have an acknowledged therapeutic value. Iron may be given in the form of vinum ferri, the ammonio-citrate, the citrate or the sulphate of iron; the latter of which preparations I prefer, as it improves the blood more effectually. This is denoted by a notable arrest or diminution of any scrofulous deposit in the glands or other parts of the body. Iodide of potassium has a beneficial influence on scrofulous deposit, apparently by promoting its absorption; but I must confess that this influence seems to me overrated. Iodide of iron is unquestionably remedial, but this is probably due to the iron rather than the iodine. Perhaps, therefore, the therapeutic value of iodide of potassium in scrofula, may be attributed to the latter ingredient; an explanation in harmony with the generally accredited efficacy of other preparations of potash in this disease. Cod-liver oil, must be regarded rather as a food than a medicine; by supplying the proportionately diminished amount of fat in the blood, relative to the fibrin. It certainly has a most marked influence on scro- fulous mal-nutrition. Cinchona bark, whether in the form of decoction or tincture, or quinine, is highly serviceable as a tonic in strengthening the circulation, and thence indirectly improving nutrition and all other functions. But it has no special influence on scrofula, and must be regarded as an adjunct to other medicinal measures. I am thus accus- tomed to prescribe the sulphate of iron in doses of three to five grains, with one or two grains of the disulphate of quinine, three times a day; coupled with a teaspoonful of cod-liver oil. Local treatment has some effect on the chronic enlargement of glands, and of other parts, arising from scrofulous deposit. Applications of the compound tincture of iodine, or the stronger iodine-paint, may be ad- vantageously aided in their stimulant operation by the pressure of strap- ping with soap plaster, or bandaging. Usually, however, these glandular enlargements will not subside, at least under topical treatment. When abscess forms, and discharges subsequently as an ulcer ; these results must be treated accordingly. Much has been said about the virtues of caustic potash and other barbarous modes of apparently punishing a scrofulous abscess or ulcer; but there need be nothing peculiar in their local treat- ment, and it should ever be remembered that constitutional treatment can alone have any curative efficacy in scrofula. Operations for scrofulous conditions of the bones, joints, or other parts, should be determined by the same consideration. Constitutional treatment Avill often succeed in averting the necessity for excision or amputation ; a highly important consideration, since any local form of a constitutional disease is always an unfavourable condition for operation, and the removal of the part affected can in no way cure' that disease as the primary cause. Hence, also, the postponement of such operation may not unfrequently be justifiable; and until the local condition be- comes more defined, or its progressive extension renders operative inter- ference imperative, whether with regard to the part affected or its reactive influence on the general health. m 162 GENERAL PATHOLOGY AND SURGERY. Scurvy and Purpura. General Symptoms.—Scurvy and Purpura are alike, manifested by haemorrhages into many textures, occurring contemporaneously or con- secutively ; and it will be readily imagined that these haemorrhages occur with greater facility in some textures than in others. Into cellular tissue, for example, blood is very apt to escape. Such spontaneous haemorrhages result from alterations which the blood itself has undergone. Scurvy.—Symptoms.—The symptoms of scurvy may be well illustrated by a supposed case. A sallow and dejected-looking man, whose strength has been gradually failing, becomes the subject of haemorrhages ol a peculiar kind. The gums are turgid, spongy, and rotten; they ooze blood on the slightest pressure; the teeth loosen in their sockets and drop out. This fungous condition of the gums ceases abruptly at the reflexion of the mucous membrane to the lips, which are extremely pale, so also are the tongue, fauces, and inside of the cheeks. In some rare instances, however, this lividity extends nearly all over the hard- palate. Red or livid spots are found—principally on the legs—together with bruised- looking patches, of a yellowish-green colour, swollen and hard as brawn. Extensive effusions of fibrin rather than pure blood—forming very hard, broad, and painful swellings—are found imbedded in the deep cellular texture and between muscles. Over these fibrinous mats, the skin sometimes retains its natural colour, but usually appears bruised— is always thickened and brawny, and adherent to the subjacent textures. Swellings such as these occur particularly in the thighs and legs, but most commonly in the hams, occasioning stiffness and contraction of the knee- joint. Nodes also arise from this effusion taking place between the bones and their periosteal investment; the tight swellings formed thereby giving great pain upon the slightest motion, even by turning in bed. None of these effusions, whether of fibrin or blood, ever suppurate ; nor do the nodes just mentioned, however large their size, ever cause the bone to exfoliate. The dark livid or purple colour of scurvy overshadows any skin- eruption, wound, or ulcer, which may chance to be present during this disease. A dark grumous coagulum juts out from the surface of an ulcer ; and this—which, owing to its appearance, has been named by sailors bullock's liver—often attains an incredible size in the course of a single night. To conclude the catalogue of haemorrhagic lesions, repeated issues of blood from the nose are common ; blood may be coughed up or vomited, lost by the bowels, and perhaps passed with the urine. Scurvy is apt to prove fatal suddenly, from exhaustion. This remark- able feature in its career, with others of instructive moment, were exem- plified in an equally remarkable manner during Lord Anson's expedition, 1740-44. The narrative states :—" Many of our people, though confined to their hammocks, ate and drank heartily, were cheerful, and talked with much seeming vigour and in a loud, strong tone of voice ; yet, on their being the least moved, though it was only from one part of the ship to another, and that in their hammocks, they immediately expired; others, who confided in their seeming strength, and resolved to get out of their hammocks, died before they could reach the deck. It was no uncommon thing for those who could do some kind of duty and walk the deck, to drop down dead in an instant, on any endeavour to act with their utmost vigour; many of our people having thus perished during the course of this voyage." SCURYY AND PURPURA. 163 Purpura.—Similar Symptoms characterize Purpura, but there is not the same marked dejection and feebleness, nor are the gums always fungous. Extravasation of blood occurs in the form of small, round, purple spots, rather than parti-coloured blotches. These spots of blood are scattered in almost every texture. According to Sir Thomas Watson's experience,* they are not peculiar to the skin, nor to the subcutaneous tissues, but occur occasionally upon all the internal surfaces also, and within the substance of the viscera. For example, on the mucous mem- brane of the mouth, throat, stomach, and intestines; on the pleurae and pericardium, in the chest; on the peritoneal investment of the abdominal organs; in the substance of the muscles ; and even upon the membranes of the brain, and in the sheaths of the larger nerves ; and they may be accompanied with large extravasations of blood in most of the vital organs of the body. Such lesions are necessarily perilous. Bateman states that he witnessed three instances in which persons were carried off, while affected with purpura, by haemorrhage into the lungs. Watson saw two post-mortem examinations, in both of Avhich a considerable quantity of blood was found spread over the surface of the brain, between its mem- branes ; and- in one of these cases blood was extravasated also into the cerebral substance, with extensive laceration. Blood-origin.—Scurvy and Purpura are plainly of "blood-origin." The blood itself spontaneously exudes, and appears as a bruise, yet without any bruising force having been applied. This haemorrhage and ecchy- mosis takes place in many textures, and visits one after another. The whole organism, in fact becomes leaky, yet without the blood-vessels themselves being in any diseased state. Blood-pathology.—Scurvy.—To what morbid condition of the blood must scorbutic haemorrhage be ascribed ? The blood has undergone remarkable and significant changes of colour ; from the florid red of health, it has assumed a dark brown or green tint; it appears, also, only half coagulated, the supernatant serum being of a livid colour. Again, the red corpuscles are observed by Drs. Ritchie and Buchananj to have become irregular in their outline, their disks more flattened, and more disposed to cohere together and aggregate into large insulated masses, than the corpuscles of healthy blood. These peculiar appearances are denied by other observers, who regard them either as inconstant or alto- gether absent. Dr. Garrod, for instance, affirms, that recent examinations have shown the blood not to be in a dissolved state, as Avas formerly sup- posed, but that the globules are normal in appearance, the clot firm and frequently buffed and cupped.^ The balance of evidence, however, preponderates in favour of the characteristic colour and fluidity of the blood, and the collapse of the red corpuscles. The chemical constitution of scorbutic blood is doubtful. In the present state of Chemical Pathology, according to one authority, potash is deficient. Dr. Garrod's analyses§ lead him to conclude that the proportion of this alkali is reduced. Other authorities—Becquerel and Rodierll—find the proportion of soda increased in scorbutic blood, and that of fibrin diminished. * Lectures on the Principles and Practice of Physic, 4th Edit. t Edin. Month. Journ., July, 1S47. X Ibid., Jan. 1843. § Ibid., 1848. II Pathological Chemistry, 1853. M 2 164 GENERAL PATHOLOGY AND SURGERY. Treatment.—Scurvy.—The preventive and curative treatment of this disease, is alike dietetic. It is an undoubted fact that certain articles of diet possess anti-scor- butic properties. Lemon-juice is the grand anti-scorbutic, whereby thousands of persons have been rescued, who otherwise would inevitably have perished from scurvy. 1457 cases of scurvy were sent to Haslar Hospital in the year 1780. Subsequently, in 1795, lemon-juice Avas provided by order of the Admiralty, through the representations of Sir Gilbert Blane and Dr. Blair. Then only one case of scurvy appears in the hospital returns for 1806 ; and for 1807, one. Potatoes, Avhether in a raw state or cooked, are equally anti-scorbutic. Many other articles of diet, more or less in use, are enumerated by Dr. W. Budd,* and their anti-scorbutic properties compared. So far, the prevention of scurvy is practicable. But this kind of knowledge is empirical; we are ignorant (as Dr. Budd justly remarks) of the essential element common to the juices of anti- scorbutic plants, and in which their efficacy resides. Therefore, one plant cannot be substituted for another—prior to actual experience of its anti-scorbutic value—with the sure and certain prediction that it Avill prove equally efficacious, or more so. And why are we still ignorant of this " essential element," and incapable, consequently of substituting an untried for a known anti-scorbutic ? Because the " blood-condition " essential to scurvy is yet unknown, and that something, by virtue of which various plants are anti-scorbutic, is therefore equally unknown. Accord- ingly, the prevention of scurvy can be determined only by the results of actual experience. Mark the further consequences of this empiricism. If potash were assuredly known to be the thing in question, it could be procured in almost any emergency from the ashes of any plant or of any wood, and especially, as Dr. Garrod has suggested, from that ubiquitous weed, tobacco, which is rich in potash. In the present state of knowledge, the commissariat of an army, a navy, or commercial marine—ever liable to be placed in straitened cir- cumstances with regard to all food—are in the dark on this most critical point. In encampments far from home, during sieges and long voyages, the allowance of lemon-juice has perhaps long been exhausted, and fresh vegetables are a dream ; when, therefore, under these adverse circum- stances, scurvy stealthily threatens, with pallid hue and dejected mien, the light of Pathological Chemistry would supply an unerring guide in search of that yet unknown something—be it potash or whatever else— by which the impending scourge would assuredly be averted. It might be possible, by a simple process perhaps, to extract that needful something from an abundant source at hand, in a locality otherwise well-nigh barren and desolate. To conclude, on behalf of the prevention of this disease ; any new and untried kind of food cannot be substituted, in an emergency, for another less plentiful; and, should all food run short, then the essentially anti- scorbutic constituent cannot be extracted from substances perchance close at hand, in which, like a precious pearl, it remains undiscovered, while scurvy is already overshadowing its victims. Empirical experience is our only resource under these circumstances, * Library of Medicine, art. Scurvy. RHEUMATISM AND GOUT. 165 and the rules which it authorizes for our guidance are necessarily of a very general character. They are enumerated by Dr. Budd as follows : — Firstly.—Anti-scorbutic properties reside exclusively in substances of vegetable origin. Secondly.—These properties are possessed in very different degrees by different families of plants; least so by the farinaceous, as wheat, oats, barley; most so by the succulent, as the aurantiae, comprising oranges and lemons ; lastly by potatoes. Thirdly.—The anti-scorbutic property is impaired by the action of strong heat; nevertheless, boiled potatoes are anti-scorbutic (Dr. W. Baly) ; impaired, also, by vinous fermentation, but improved probably by acetous fermentation. To show the difficulty of determining the essential treatment of scurvy empirically, I might add, in striking contrast, the conclusions of Dr. Christison in favour of azotized substances, and of animal origin, perhaps exclusively, such as milk. These and similar discrepancies, on the part of practised observers, should direct the attention of chemists to the unknown " blood-condition," as the only standard of comparison whereby to estimate the anti-gcorbutic value of different substances, their composition being presumed to be known. Purpura.—Although resembling scurvy in appearance, the curative treatment of purpura, by abstinence, purgation, and venesection, as recommended by the late Dr. Parry, of Bath, is altogether at variance with that which is so efficacious in cases of scurvy; and points, therefore, to some essential difference between these two diseases, otherwise allied. The manifestations of both are unquestionably of blood-origin, yet essen- tially different in this respect; and not until Chemical Pathology has determined the blood-condition peculiar to Purpura will it be possible to interpret rightly the whole etiology of this disease. Tts rational preventive and curative treatment will follow. CHAPTER VI. rheumatism and gout. Rheumatism.—Symptoms and Diagnosis.—Rheumatism is manifested by an inflammation affecting some portion of fibrous tissue; the ligaments and tendons around the joints, are more commonly selected, sometimes the fasciae, and very probably the pericardium and endocardium. This inflammation is specific. It is denoted, just as common inflammation is expressed, by redness, heat, pain, and swelling; but rheumatic inflamma- tion is characterized by not tending to the effusion of plastic lymph, nor to suppuration and gangrene; unless, indeed, some other texture besides fibrous tissue shares the inflammation, as synovial or serous membrane, Avhen its products are the same as those of ordinary inflammation. Fever.—This local condition is preceded by and accompanied with inflammatory fever, in perhaps its highest degree,—contrasting, therefore, in every Avay with fever of the typhoid type. A strong, rapid, hard pulse; headache without any delirium, excepting when pericarditis or 166 GENERAL PATHOLOGY AND SURGERY. endocarditis ensues; acid perspirations and urine; these are the chief phe- nomena of rheumatic fever. And this fever not only precedes the local inflammation; but possibly runs its course without any such manifes- tation. _ , Blood-origin.—Rheumatic inflammation, whether exhibited by the joints, the fasciae, or the heart, is evidently due to the operation of some morbid blood-condition; and for two reasons more especially. The very fact of the same inflammation affecting, possibly, "many parts"—e.g., many joints—simultaneously, points to the blood as its common cause. So also does the " metastatic" character of this inflamma- tion. Passing from one joint to another—from the shoulders to the elbows, or from the knees to the ankles, perchance back again to the joints first affected, and probably thence migrating to the heart; these and similar alternations of the same character of inflammation betoken some morbid condition of the blood, which, as a reservoir supplying in common all parts of the body, is turned on, as it were, more abundantly (by inflam- mation), now on this part, now on that. The "symmetrical" distribu- tion of chronic rheumatism,* in many cases, affecting as it does corre- sponding parts of either half of the body, is further evidence of there being a 'blood-disease in operation ; while such distribution exhibits also the elective power of similar portions of the same texture. Blood-pathology.—But although the blood, vitiated in some way, is determined to the fibrous texture, by virtue of its elective power, we cannot say what particular ingredient, normal or foreign to the blood's composition, is appropriated thereby. The texture undergoing rheu- matic inflammation selects something—but what ?—from the blood. Judging by the acid state of certain secretions—perspiration, saliva, and urine—during an attack of acute rheumatism, it would appear that an acid of some kind prevails in rheumatic blood; and, first suggested by Prout,f other authors,—Todd,| Fuller,§ C.J. B. Williams,|| Headland,^ &c. —have since concurred in believing that this acid is lactic acid. It is urged that, as the perspiration contains lactic acid, with lactates of soda and ammonia, and that exposure to cold, checking this secretion, is well known to be frequently followed by an attack of rheumatism; that therefore this disease is due to an accumulation of lactic acid in the blood. But then, sufficient exposure to cold ought invariably to have this effect; or—making allowance for individual peculiarities of consti- tution—at least in many instances such Avould be the effect of exposure. Moreover, the not unfrequent spontaneous origin of rheumatism in hos- pitals, where patients are protected from exposure, is irreconcilable with the theory in question. Again, it is alleged that prirnary mal-assimilation—dyspepsia, in fact, of some kind—produces lactic in excess, which .accumulates in the blood. But this theory also is not consistent with observation, so far as the absence of any symptoms of indigestion is significant. Neither has it been demonstrated that lactic acid accumulates in the * Med.-Chir. Trans., 1842. Communication by Dr. W. Budd. f Stomach and Renal Diseases, 1848, p 84. X Gout and Rheumatic Fever, 1843, p. 143. § Rheumatism, Rheumatic Gout, and Sciatica, 1860. || Principles of Medicine, 1856. 11 The Action of Medicines in the System, 3rd Edition, 1859. RHEUMATISM AND GOUT. 167 blood, as the product of secondary textural mal-assimilation ; for chemical research has failed to discover any abnormal quantity of this acid in rheumatic blood. And this fact equally tells against the supposition of its accumulation by primary mal-assimilation, or by suppressed excretion of the perspiration. >.or does uric acid superabound in rheumatic blood. Garrod's chemical analyses* establish this negative fact. In truth, rheumatic blood is decidedly alkaline.f Treatment.—Preventive.—The essential morbid condition—which, in those subject to rheumatism, is ever in operation as the cause predis- posing thereto—being unknown, the evolution of rheumatic symptoms, from time to time, cannot be averted; and as if to shoAv how compara- tively unimportant, apart from this knowledge, is that of knowing the exciting and reputed cause of rheumatism, it is useless to avoid exposure to cold, for that alone will never evoke the disease, and if the blood be charged with the unknown poison, it will arise spontaneously. Curative Treatment.—The same Avant of exact knowledge as to the nature of the rheumatic blood-poison, renders our remedial measures proportionately aimless. Whatever it be, there is probably—as with other blood-poisons—a natural tendency to elimination from the system by one or more of the excretory organs. Hence, it is not surprising, that experience should sanction the employment of medicines affecting the liver, and intestinal canal, the kidneys and skin. In acute rheumatism—with • high inflammatory fever—it may be necessary, in the first place, to reduce the general circulation by systemic blood-letting, venesection. Usually, however, a cholagogue dose of calomel, and an aperient saline, Avill prove sufficiently depletory, and remove also any source of irritation from the intestinal canal. But such measures are preliminary only. Then, the colchicum and alkaline treat- ment, is generally the most effectually anti-rheumatic. Bicarbonate of potash, in large doses—two scruples or half a drachm, combined with the Avine of colchicum in doses of ten or twenty minims ; may be administered every four hours. The joint-affections may thus subside Avithin an average period of ten days, and the urine becomes alkaline. Sometimes the colchicum producing sickness and purging, it must be discontinued, or moderated ;■ but it is desirable to keep the urine alkaline for two or three days after the joint-symptoms have subsided. This plan of treat- ment is certainly successful in many cases. In proportion as synovial symptoms .predominate, or mix themselves distinctly with the fibrous— observes Sir Thomas Watson—in proportion as the disease approaches in its characters to. gout, you may expect to be successful with colchicum. Dr. Garrod, who originated the potash-tveatment in large doses, affirms that it greatly diminishes the tendency to pericarditis and endocarditis. Nitrate of potash——still in large quantity, half an ounce to three ounces a day—is the favourite salt with some practitioners ; acetate of potash with others. The late Dr. Golding Bird trusted to the latter, given in quan- tities of half an ounce, much diluted, in divided doses, during the twenty- four hours. In three days only, it has been knoAvn to overcome the pain and inflammation, leaving the joints still swollen but placid. Iodide of potassium finds favour Avith yet other men of experience, surgeons chiefly, * Med.-Chir. Trans., vol. xxxvii., 1S54. f Ibid. 168 GENERAL PATHOLOGY AND SURGERY. and lemon-juice has been advocated by Dr. Cwen Rees. Both the latter agents answer better in the less acute form of rheumatism. All these agents are probably eliminative, principally through the kidneys. Calomel and opium, quickly pushed to slight salivation, is another plan of treatment. It would seem to be preferable in cases having a tendency to cardiac inflammation. Opium is, perhaps, most remedial in all cases of acute fibrous rheumatism. Sir Dominic Corrigan has great confidence in its efficacy. Beginning with one grain, repeated at short intervals in the twenty-four hours, he gradually increases the quantity up to an average of twelve grains during that period ; and continues it until the disease declines. In chronic rheumatism; the compound powder of ipecacuanha (Dover's Powder), guaiacum, and sarsaparilla, have reputed efficacy. It would be useless to extend the list. The general nature of the treat- ment of this disease,—acute and chronic, may be gathered from the fore- going observations. Local treatment can scarcely be of any avail for a disease which, ap- parently, naturally expends itself by inflammation of whatever part or parts may become affected. Assuredly no repressive application can be salutary. Warm fomentations are calculated to lead the inflammation, as in all other cases, to an issue by resolution. Alkaline fomentations, and especially with an alkaline and opiate solution, are found to be even more conducive to this termination. Dr. Fuller, who strongly advocates such an application, usually employs a solution of carbonate of potash or soda, about half an ounce, in nine ounces of hot water, adding six drachms of liquor opii sedativus. Flannel steeped in this hot lotion is wrapped round the inflamed joints, and then encased with thin gutta- percha. Chronic rheumatism, attended with thickening and stiffness of the joints and fasciae, may be somewhat ameliorated by warm baths, va- pour baths, shampooing, or frictions. The Turkish bath will thus prove beneficial, provided there be no heart affection of consequence. Gout. Gout is a blood-disease allied to rheumatism, but differing in its pa- thology and treatment. General Symptoms and Diagnosis.—This disease is manifested by an in- flammation affecting the joints, very commonly the first joint, or ball, of the great toe. Commencing, usually, when the individual about to suffer has retired to rest, and has enjoyed some hours perhaps of sleep, he is awoke with fixed pain in one of his feet,—mostly, as I have said, in the ball of the great toe, but sometimes affecting the heel, instep, or ankle. With this pain, cold shivering is generally experienced, succeeded by heat, as the pain—boring, grinding, and wrenching—fastens more and yet more firmly on the spot of its election. "Place your joint in a vice," said a witty Frenchman, " and screw the instrument up until you can endure it no longer. That will represent rheumatism. Then give another twist, and you will somewhat realize gout." The skin over this part is acutely ten- der, red, tense, and shining, encircled by some oedema, and by converging turgid veins. Much restlessness and excitement supervene. In vain the sufferer seeks to relieve himself of the weight of his bedclothes upon the part inflamed ; in vain he shifts his foot from place to place in search of RHEUMATISM AND GOUT. 169 a cool and easy position. The pain, remorseless, grapples yet more tightly. At length, in the course of tAventy-four hours or so, it loosens its hold gradually, perhaps suddenly. The sleepless excitement also then subsides, and the victim enjoys some temporary repose. He wakes again to undergo punishment. The toe-screw is reapplied, it may be with a turn or tAvo less ; and day by day a slighter punishment is inflicted, until at length the full penalty has been paid. The cuticle peels off the part affected, for gouty inflammation ends by resolution ; it never terminates by the effusion of plastic lymph, suppuration, or gangrene. In these respects, this inflammation and that of rheumatism concur. Eventually, after frequent attacks of gouty inflammation, the cellular texture around the joint usually becomes pervaded with a deposit of urate of soda, forming concretions, at first pultaceous, then " chalk-stones," of perhaps considerable size. The nodular fingers and toes of chronic gout is a matter of common observation. The skin over these nodules being stretched, at length breaks, and the chalky concretions are laid bare. Urate of soda has been found infiltrating all the textures of one or seve- ral joints, in synovial membrane, cartilage, the heads of bone, and liga- ments ; and usurping their place, the articulations are irreparably de- stroyed.* Constitutional Disorder.—Does any characteristic—i.e., peculiar and constant, constitutional disturbance—precede and accompany an attack of gout ? Y'es, verily—and its premonitory symptoms refer to the functions of the stomach and kidneys, more especially. Dyspepsia, denoted by in- appetency, eructations, heartburn, and acidity of the saliva; together Avith scanty urine, clear, high-coloured, and containing less than the aA'erage amount of uric acid or none at all; these symptoms portend a fit of the gout. An intolerable lowness of spirits, with general restless- ness and peevishness are not unfrequently premonitory. Blood-origin.—Chemical analysis demonstrates the presence of an excess of uric acid, with no other change, in the blood. It is, therefore, scarcely necessary to even glance at those characters in the history of gout which might otherAvise be appealed to in support of its being a blood- manifestation. The absolute test of " blood-disease" having been sup- plied in this instance directly (by chemical analysis), supersedes the occa- sion of any other evidence. But I might point to facts such as these:— Gout visits "many textures'' and parts of the body " simultaneously" or in " succession." Blood-pathology.—The blood superabounds with uric acid; but its nor- mal constituents apparently are not modified. "It is," writes Dr.Garrod,j "by the augmentation of those principles which exist in health, in such minute traces as to be detected with difficulty, that the peculiar alteration of the blood in this disease is manifested. The blood in gout always contains uric acid in abnormal quantities and in the form of urate of soda, Avhich salt can be obtained from it in a crystalline state."| It arises apparently, from mal-assimilation,—primarily, of albuminous food in the course of digestion, or secondarily, in the metamorphosis of muscular texture. Or, it may denote simply an excess of animal food over the Avants of the system. And the fact first disclosed by Garrod's analyses * Diseases of the Joints, 1850, 5th Ed., Sir B. C. Brodie. t The Nature and Treatment of Grout and Rheumatic Gout, 1859. X Trans. Med.-Chir. Soc, 1848. 170 GENERAL PATHOLOGY AND SURGERY. of the blood, coupled with the known phenomena of arthritic inflam- mation, inducing the formation of urate of soda concretions, and abun- dant deposit of urates in the urine; constitute a series of facts, which plainly declare the pathology of this disease. An attack of gout is an effort of nature—of the restorative power—to expel a poison, uric acid, from the blood. Sir Thomas Watson well describes this struggle. " Morbific matter (it may well be called a poison) is generated, or de- tained, under certain circumstances, within the body, and silently collects, in the blood; until, after obscure threats, perhaps, and prelusive mutter - ings, it explodes in the foot; and then the bodily economy, like the at- mosphere after a thunder-storm, is for a while unusually pure and tranquil." Or, gout may engage many joints at once, or flit from one to another ; or wander about, disturbing the heart, the lungs, and the brain. Hence palpitation and syncope, dyspnoea, disturbed vision and hearing, with cerebral commotion, bordering on apoplexy and paralysis. This is known as irregular, lurking, or masked gout. Sometimes, however, having settled in the foot, it suddenly disappears, and migrates to the stomach, heart, or brain; retrocedent gout as it is then called, being unlike the retreat of an ordinary foe—an assault on the very fortress of life. Less perilous migrations are witnessed, when gout betakes itself to the urethra, occasioning a scalding discharge ; to the testicle, constituting one form of orchitis ; to the eye, giving rise to ophthalmia. All these manifestations of irregular and migratory gout should be borne in mind, otherwise, the disease in some form might be overlooked. In whatever shape gout may have appeared, whether regular, disguised, or migratory, its decline is marked and measured by a flow of urine, surcharged with uric acid,* thus relieving its accumulation in the blood. Detection of Uric Acid in the Blood.—The ready method proposed and practised by Dr. Garrod for this purpose, and for which the abstraction of only a very small quantity of blood is requisite, he thus describes as the "uric acid thread experiment;"j— " Take from one to two fluid drachms of the serum of blood, and put it into a flattened glass dish or capsule; those I prefer are about three inches in diameter, and one-third of an inch in depth : to this add ordi- nary strong acetic acid, in the proportion of six minims to each fluid drachm of serum, which usually causes the evolution of a few bubbles of gas. When the fluids are well mixed, introduce a very fine thread, con- sisting of from one to three ultimate fibres, about an inch in length, from a piece of unwashed huckaback, or other linen fabric, which should be depressed by means of a small rod, as a probe or point of a pencil. The glass should then be put aside in a moderately warm place until the serum is quite set and almost dry ; the mantel-piece in a room of the or- dinary temperature, or a book-case, answers very well, the time varying from twenty-four to forty-eight hours, depending on the warmth and dryness of the atmosphere. " Should uric acid be present in the serum in quantity above a certain small amount, noticed below (vide Work), it will crystallize, and during its crystallization will be attracted to the thread, and assume forms not unlike that presented by sugar-candy on a string. This may then be examined The characters of the urine iu this, and other morbid conditions, are described in the ' Urinary Pathology and Deposits' of the Author's Work on the " Irritable Blad- der," 2nd Edit., 1867. t Op. cit., 1859. RHEUMATISM AND GOUT. 171 by a linear magnifying power of about fifty or sixty, procured with an inch object-glass and low eye-piece, or a single lens of one-sixth of an inch focus answers perfectly. The uric acid is found in rhombs, the size of the crystals varying with the rapidity with which the drying of the serum has been effected and the quantity of uric acid in the blood." To ensure perfect success in this experiment, several precautions are necessary, for which the reader is referred to Garrod's Work, pp. 111-113. An amount of uric acid equal to at least 0.025 grains in 1000 grains of serum, in addition to the trace existing in health, must accumulate before this experiment gives indication of its presence. Premonitory symptoms, however, coupled perhaps with the signal given by this test, announce that gout is impending. Hygienic Causes.—Certain habits of life predispose to gout, and cer- tain other habits of an opposite character have an opposite tendency. Indulgence in animal food more particularly, and stimulating drinks; generally, in point of fact, what is called " rich living," together Avith a sedentary, idle life; these are the acknowledged parents of gout; while moderation in the "pleasures of the table," even abstinence, with a life of active exercise, has no such offspring. Luxury and ease have long since been mistrusted as unqualified advantages compared with the appa- rent hardships of daily bread, earned by daily labour ; so much so, that Abernethy's pithy advice, " Live on sixpence a day, and earn it,"— pointing, as it does, to the two elements, food and exertion, in relation to gout—has passed into a proverb. Treatment.—Preventive.—The regulation of diet by exercise—of bodily supply by expenditure—is the preventive measure furnished by expe- rience. But experience is insufficient for practical purposes. It affords no clue to the right understanding of the physiological relation subsisting between food and exercise, nor of the pathological relation between these hygienic requirements Avhich determines the rational prevention of gout. It is the peculiar province of Science to supply the interpretation and elucidate the significance of facts. Knowledge thus becomes appreciated, and applied because appreciated. Physiological Chemistry having first demonstrated the fact that all kinds of animal food, more especially, furnish uric acid in their transit through the body, by indigestion, or by metamorphosis of the muscular textures ; it became obvious that the balance between the production and elimination of uric acid can alone be adjusted and regulated by a supply of animal food in proportion to its waste by bodily exercise. Then Chemical Pathology contributed the additional and complemental fact, that uric acid existing as urate of soda in abnormal excess in the blood, is the materies morbi of gout. Obviously, therefore, the preventive measure Avhich should be directed against such accumulation is this :— To allow only that particular amount of animal food which, with daily exer- cise in proportion, will preserve the blood free from uric acid, short of the trace existing in health. Now this goes a step beyond mere experience. Guided by an exact knoAvledge of the essential morbid blood-condition from whence proceed all the phenomena of gout, we are enabled so to regulate the health as to prevent this disease. Exact information of the blood-condition, respect- ing any individual in question, can be readily obtained by abstracting a very small quantity of blood for analysis, or by examining the serum exuded under the application of a blister. 172 GENERAL PATHOLOGY AND SURGERY. Moreover, by this scientific knowledge we are led to rationally admi- nister certain medicines in aid of our hygienic preventive measures. Alkalies—of which the bicarbonate of potash is perhaps the most effica- cious for prolonged use—may be administered daily, to neutralize any fresh accession of acid; and colchicum, as a diuretic, will aid the elimi- nation of urate of soda by the kidneys. The mineral waters of Vichy, Wiesbaden, and other places of known repute, owe their virtue chiefly to similar qualities ; but in speaking of the principle of prevention, I need not enter further into detail. To illustrate the prophylactic management of gout, Dr. Garrod relates a case, on the authority of Sir H. Halford, in which colchicum with quinine taken in moderate doses daily, gave immunity for two years, when previously scarcely two months elapsed without an attack. Curative Treatment. — Having due regard to the origin of the blood- disease,—by mal-assimilation, primarily or secondarily; hygienic mea- sures are also curatively important. A reduced proportion of animal food is obviously the leading curative measure, and active exercise daily to increase the elimination of any excess is equally necessary. No remedial measures are at present known for directly correcting mal-assimilation in respect to lithic acid or other products. The effect of increased bodily exercise may be to increase the destructive metamor- phosis of the highly nitrogenous textures—i.e., muscle, and thus directly increase the production of lithic acid : but this may also react beneficially in subsequently correcting the mal-assimilation. Lithic acid passing off in the urine as lithate of ammonia is liable to be decomposed by the action of any free acid present in the urine; and lithic acid itself being insoluble appears as a deposit of reddish-yellow sand, consisting of crystals, which may aggregate and form a calculus. Hence the administration of alkalies to neutralize the acidity of the urine is indicated, of which bicarbonate of potash is, perhaps, the best for oft- repeated use. Other alkalies employed for this purpose are the bicar- bonate of soda (" Vichy water") the acetates, tartrates, and citrates of soda and potash, phosphates of soda and ammonia, and borates of soda and potash. Conversely, the removal of any source of acidity is also in- dicated ; but this refers again to hygienic considerations. With regard to food, the vegetable acids, or that which will form them, as sugar or starch in the food, should, in Dr. Bence Jones' opinion, be prohibited. On the other hand, free perspiration to eliminate the acids of the sweat, the retention of which would precipitate uric acid in the urine, is scarcely less important. Warm clothing, warm bathing, friction with horse- hair gloves and belt, an excellent stimulant, and diaphoretics, are most efficacious. Lithate of ammonia being soluble in urine at the temperature of the body, its solution is thus secured, provided only that fluid be not over- charged. Dilution of the urine will best prevent supersaturation and deposit. The free use of aqueous drinks or soda water, is calculated to fulfil this indication, and thus probably prevent the formation of a lithate of ammonia calculus. Diuretics, which increase the secretion, will also aid the dilution, of urine, and, moreover, will tend to eliminate lithic acid or lithates, from the system. The wine of colchicum, in doses of ten minims and upwards three times a day, prescribed with the carbonate of potass to keep the lithic acid in combination, the resulting lithates themselves being further SYPHILIS. 173 held in solution by the administration of diluents—Avill together carry off both, and soothe the irritabiUty of the bladder which accompanies their discharge. Salient aperients seem to contribute to this desirable result. Any prolonged subjection to such a course of elimination, requires also the simultaneous action of small doses of blue pill, apparently to main- tain the proportional secretion of bile, which otherAvise being virtually retained as compared with the secretion of urine, wordd disturb the balance of their constituents in the blood. DISEASES OF CONTAGIOUS ORIGIN. CHAPTER VII. By the term Contagion, I mean the communication of disease by external contact, as distinguished from communication by inhalation or infection. The disease produced is not necessarily constitutional, but possibly merely a local affection; for example, Itch, as contrasted with secondary or constitutional syphilis. Still, under the same general heading may be associated certain re- markable species of blood-disease, Avhich have severally received names of various kinds. Syphilis, Erysipelas, Pyaemia, Hospital Gangrene, Hydro- phobia, Snake-bites, Malignant Pustule, and Glanders; are all naturally associated together as being contagious, or the offspring of contagion. But of these, the first four are derived from the human species, the re- maining four from animals. This difference allows a corresponding divi- sion of the whole class. Syphilis. Syphilis is essentially a blood-disease, produced by the introduction of a virus or poison into the general circulation. But its introduction is attended by certain tolerably definite manifestations in the skin or mucous membrane, and proximate lymphatic glands, in the form of chancre and bubo respectively; constituting local or primary syphilis; Avhile the consequent blood-disease is manifested by certain tolerably definite inflammatory modifications of nutrition in the skin, mucous mem- branes, eyes, testicle, periosteum, bones, and other parts—constituting constitutional or secondary syphilis. A concise description of this series of manifestations will lead to their diagnosis. Hoav far every form of chancre and bubo, as local syphilis, may be also primary or causative, in relation to constitutional syphilis, itself necessarily secondary, will be duly con- sidered subsequently. Local Syphilis.—(1) Chancre, and its Diagnosis.—Chancre is said to be a primary syphilitic sore or ulcer. Commencing at an uncertain period, possibly a month, but generally from three to five days, after in- fection ; a trifling itching is experienced, affecting, usually, some spot in the furroAV at the base of the glans penis, near the fraenum, or it may be on the prepuce or the skin of the penis itself; there soon appears a small pimple, whose summit speedily becomes a vesicle, containing at first a thin transparent fluid lymph, gradually becoming thicker and opake, in fact, purulent. If the syphilitic virus be introduced through a crack or abra- 174 GENERAL PATHOLOGY AND SURGERY. sion, which may happen in the act of intercourse or have existed pre- viously ; the chancre forms as an ulcer, without any incipient pimple, vesicle and pustule; obviously because the cuticle there raised by secre- tion, was here removed. Otherwise, this papule, vesicle, and pustule, is alike the typical mode of origin of all chancres ; yet how diversified their subsequent appearances, and how like those of ordinary ulcers. Their diagnosis is, perhaps, impossible. The granulating or healing sore alone excepted, we may recognise :—the simple syphilitic ulcer : the indolent and indurated; the irritable; the phagedaenic; the inflamed; and the sloughing phagedaenic. When the pustule of an incipient chancre bursts, a " simple " ulcer is presented, Avithout any special characters. It is a small circular cup- shaped cavity, having a smooth interior, without granulation, discharging a thin serous fluid, or glazed with a little adhesive lymph, and set in apparently healthy texture. This, the first of all primary syphilitic ulcers, may, however, about the end of the first week and never before the third day, become indurated, by effusion of plastic lymph beneath its base, and around. A single exception is observable in chancre on the glans penis, which never acquires induration ; it is here simply a spot denuded of cuticle, and presents a red, moist, glistening, flat surface. When " confined to the base of the ulcer," such induration—elastic cartilaginous, and terminating abruptly—was regarded by Hunter* as characteristic, and the specific diagnostic mark of true chancre. Yet Hunter himself acknowledged, in the sentence immediately preceding this, his definition, that the indurated base is not peculiar, being common to other indolent ulcers. A slight modification, as it appears to me, of Hunter's doctrine, has since been revived and advocated by M. Ricord,t who affirms that carti- laginous induration at the base, and around, a primary syphilitic ulcer, is absolutely pathognomonic of " infecting chancre," or that species which accompanies and denotes constitutional syphilis. He regards this character as the local expression, by chancre, of the syphilitic blood-disease—in short, the first secondary symptom. But precisely the same condition of induration may be produced arti- ficially by irritating applications—e.g., kali purum (Hennen), corrosive sublimate (Acton), and better still, says Ricord, by chromate of potash, or by nitrate of silver, the nitric and sulphuric acids; " so as to deceive even the most careful and experienced practitioners." It was thus, for example, that Abernethyt. was betrayed by an indurated sore, and recom- mended mercury to be rubbed in to salivation! Observing, however, that it produced no amendment, and ascertaining that the hardness had several times subsided and returned, an unirritating dressing was used, when the induration disappeared without the use of mercury. Under other circumstances, pertaining rather to the state of the general health, and the condition of the digestive organs in particular, the primary ulcer becomes " irritable," that is to say, painful and disposed to bleed easily. This, therefore cannot be considered a specific sore. Nor again is the " phagedaenic" in any way characteristic. The same irregular worm-eaten sore, with sharp, undermined edges, may either be syphilitic, or proceed from the depraved constitutional condition by which a sore * Venereal Disease, edit. Home, 1810, p. 229. t Lecture on Chancres, trans. C. F. Maunder, 1859. X Surgical Observations, 1804, p. 135. SYPHILIS. 175 becomes phagedaenic. Less characteristic is an obviously "inflamed" ulcer, and that mixed appearance knoAvn as " sloughing phagedaena." In short, the primary syphilitic ulcer may assume many characters, but none of them are peculiar to syphilis. Primary syphilis cannot thus be diagnosed with more than equivocal probability. This negative result of observation is supported by the united testi- mony of all who during the present century have most patiently watched, in vain, to discover any characters whereby chancre can be surely distin- guished. First:—Rose* (1817), Avhose experience in the hospital of the Coldstream Guards ranged over a large number of cases, admitted that although there are many symptoms common to chancres, they are not entirely peculiar to them. Hennenf (1829) acknowledged Avith regret that there are " not any invariable characteristic symptoms by which to discriminate the real nature of the primary sore;" and, having witnessed many instances of self-deception, in attempting to diagnose a sore for the cure of Avhich mercury is indispensable, from one of a different nature, he repudiated the pretensions of those who assume to themselves the posses- sion of a " tactus eruditus " by which they can distinguish this kind of chancre. Recurring to the diagnosis of chancre, rather than the kind, Mr. Bacot's experience^ (1829) led him to affirm, that chancre may present every variety of appearance to which a breach of surface is subject; and Colles§ (1837) stated, "as the result of long, attentive, and anxious observation," that primary venereal ulcers present an almost endless variety of character. To this effect also were the observations of Wallace|| (1838) ; for, says he, neither the mode of origin, nor the form, nor the colour, nor the size, nor the number of the ulcers of primary syphilis, are pathognomonic. Acton^f (1851) avowed it was incontro- vertible, that other sores, not of a specific nature, may assume all the as- pect of real chancres ; and Labatt** (1858), considering the great variety of appearances presented by primary ulcers, experienced the difficulty of classifying them, and confessed that hitherto every such attempt had ended only in disappointment. More recently (1860) Mr. H. Lee,-|"|- recognises four varieties of Primary Syphilis— First.—The inoculated part may become affected with the adhesive form of inflammation, in Avhich lymph is poured out either in the sub- stance or on the surface of the part. Second.—The inoculated part may, Avithin a few days of the applica- tion of the poison, be affected with suppurative inflammation. Third.—The absorbents may assume an active share in the morbid process, and taking up some of the infected parts, and with them portions of the syphilitic poison, produce an acute inflammation of a lymphatic gland. This form of the disease is termed ulcerative inflammation. Fourth.—The morbid action may terminate in mortification. Of this there are two practical subdivisions:— (a) Death of the Avhole infected part, AArhich is then throAvn off as a slough; (b) Dissolution and death of a part only of the contaminated structure, leaving a part still infected. * Med.-Chir. Trans, vol. viii. p. 358. f Milit. Surg., 1829, p. 525. X Treatise on Syphilis, 1829, p. 149. § Prac. Obs. on Venereal Disease, 1837, p. 75. || On Venereal Disease, 1838, p. 84. ■i Diseases of the Urinary and Generative Organs, 1851, p. 380. ** Obs. on Venereal Diseases, 1858, p. 48. ft System of Surgery, ed. T. Holmes, vol. i. 176 GENERAL PATHOLOGY AND SURGERY. Situation.—The external parts of the genital organs are obviously the common situation of chancre, and some parts are more especially liable. Thus, in the male, that portion of the penis is commonly the seat of chancre, which having been exposed in sexual intercourse, is apt to retain any secretion with which it came in contact. Hence, the furrow between the glans and prepuce, and perhaps near the fraenum is the most frequent situation; but chancre may form on the inner surface, or at the margin of the prepuce, or on the fraenum; sometimes on the glans, or at the orifice of the urethra, or perchance on the skin of the penis. Urethral chancre is, however, not unfrequently met with ; the chancre being situated immediately within the orifice of the urethra, or higher up in the canal. In the one case, it may easily be seen on just everting the lips of the urethral aperture ; in the other case, it can be felt as a more or less nodulated induration of the urethra when pressed between the thumb and finger. Chancres thus situated have been found by Ricord to extend along the whole canal up to the bladder, in rare cases. Urethral chancre emitting its discharge from the external orifice, may be mistaken for gonorrhoea; but, while their diagnosis cannot be determined by the variable appearance of the discharge, inoculation will evince its true nature ; a chancre being produced if the matter be syphilitic, and not by gonorrhoeal discharge. The pre- sence of a nodulated induration in the urethra will corroborate the diagnosis. In the female, also, the external genitals are the common situation of chancre, as just within the labia minora; less frequently on the mucous membrane of the vagina, or on the os uteri or within the cervix. Ex- amination will readily discover a chancre when situated externally ; but, the speculum must be used to detect the presence of a vaginal or uterine chancre. In certain unnatural situations, chancre may occasionally be found; as at the anus, or on the lips of the mouth ; suspicions of practices which need not be named. (2) Bubo and its Diagnosis.—What is syphilitic bubo ? Perchance its physical characters may be more uniform and peculiar, although available only at a later period than those of chancre, to guide our diagnosis. Now it is alleged that bubo denotes absorption of the syphilitic virus from the primary sore, which, on its way to the blood, through the absorbents, irritates the absorbent glands, whereby they become swollen and hard, and perhaps suppurate. Compared with chancre, bubo can scarcely be called a primary symptom, for although the time of its acces- sion after chancre is uncertain, it is always somewhat later. In many rases bubo never supervenes, the syphilitic virus apparently passing on uninterruptedly to the blood, without any demonstration during its journey, as if a highway robber should overleap a toll-bar without pay- ing the customary toll. This uncertainty respecting the formation of bubo, and delay in its coming, seriously impair its diagnostic value. On the other hand, bubo may possibly, although not probably, occur without previous chancre. Bubo may be the only primary symptom. Such buboes therefore have been named " primary buboes," and by the French " bubons d'emblee." Delpech, Sir A. Cooper, and many others deny their existence ; wdiereas Fallopius, Hunter, Wallace, Lagneau, Swediaur, Bertrande, E. Wilson, and other authorities affirm that they do occur. SYPHILIS. 177 As being possibly the only primary symptom present, the question presses—are there any characters whereby syphilitic bubo can be as- suredly identified ? If no peculiar characters distinguish it, then bubo, no less than chancre, alone considered, is equivocal evidence in our diagnosis of primary syphilis. Firstly.—There is the possibility of bubo arising from irritation of the lymphatics, in some part more or less remote ; the irritation having apparently been propagated along the course of the absorbents leading to the SAVollen glands, without, however, any poisonous matter having been absorbed. The femoral glands becoming enlarged from the irritation of a chafed toe is a familiar illustration. This sympathetic bubo is easily distinguished by the kind of local cause in operation. Secondly.—But if swelling of the lymphatic glands exist alone, un- accompanied and not preceded by any kind of sore, in any situation ; then, is it possible to pronounce that swelling a syphilitic bubo ? Many species of bubo are attributed to syphilis, yet they all appear to be one and the same kind in different stages of progressive inflammation. Beginning as a hard and somewhat painful swelling of the lymphatic gland usually nearest to the spot whence the poison is absorbed ; the absorbents themselves proceeding to the enlarged gland, share this inflam- matory induration, and sometimes feel like hard whipcord. Along the back of the penis such cords may be felt leading to the groin, where mostly, just above Poupart's ligament, lies the swollen gland. Or, in the female, if a chancre be situated anteriorly on the vulva, this swelling is discovered at the external abdominal aperture ; and if situated posteriorly, then betwixt the labium and the thigh, inflamed lymphatic vessels lead to a SAVollen hard gland in the groin. Occasionally bubo is situated elseAvhere, when the vessels of absorption pass through other than the inguinal glands. Hunter saw a syphilitic bubo far down on the thigh; and he met with other instances on the loAver part of the abdomen. Wherever placed, as the gland enlarges it successively engages the surrounding cellular tissue and skin; the latter becoming inflamed and adherent, fixes the tumour. Suppuration may ensue. The skin acquires a stretched and shiny appearance, while the cuticle desquamates in receding circles, and the cutis becomes thinner. At some point fluctua- tion can be felt, the thin skin cracks, matter is discharged, and a cavity exposed that speedily assumes the condition of an ulcer. Up to this point, the most critical observer could detect nothing to characterize the swelling syphilitic bubo, beyond the fact of its association Avith a sore, the nature of Avhich, however, is itself doubtful; Jess certain, therefore, would the diagnosis be Avere bubo present alone. Carmichael* acknowledges his inability, before ulceration, to determine Avhether bubo be syphilitic or not; and if the former, Avhat degree of venereal disease; but that Avhen ulceration takes place, the bubo partakes of the same mildness, or malignity, as the primary ulcer from Avhich it origi- nated. Yet these signs are equivocal, for, like chancre, the ulcer of an open bubo at once acquires all the characters of some kind of common ulcer; it may be the indurated and indolent, the irritable, phagedaenic, inflamed, sloughing phagedaenic. The size of this ulcer, of course, varies; usually not larger than the bubo itself, occasionally, and fortunately but seldom, it becomes enormous, extending imvards over the perinaeum, or * Clin. Lectures on Venereal Diseases, 1842, p. 109. X 178 GENERAL PATHOLOGY AND SURGERY. downwards over the thigh, or upwards, perhaps, as high as the navel, while its depth may threaten the femoral artery. Now all this—the origin and progress of an inguinal bubo—does not pronounce it syphilitic. Alone, its physical characters are fallacious— association Avith a sore elsewhere, the nature of which, as determined by its physical characters, is doubtful, renders the evidence only probable in some degree. Is there any pathognomonic sign or test which converts this indefinite probability into certainty ? Inoculation.—Does Inoculation supply the requisite test? The pus from a chancre, or bubo, being introduced beneath the skin of any part by a lancet charged therewith, produces a chancre. Thence in like manner another may be produced: first a pimple, then a pustule, then an ulcer. This poAver of reproduction was known to and used by Hunter. Mr. Lee affirms that inoculation, as a rule, is of no value in determining the nature of an infecting sore. That supposed instances to the contrary, as adduced by Dr. Sperino, were simply suppurating sores, with some amount of accompanying induration. But that out of 100 instances of indurated chancre, in one case only did inoculation succeed upon the patient who had the disease. On the other hand, Evans, Bell, Sperino, and other observers have alike insisted on the value of this reproductive test, and Ricord himself, who almost accords to " induration," the rank of a pathognomonic sign of the "infecting chancre," nevertheless regarding chancre as a distinct species of ulcer ; acknowledges that its individuality " exists neither in its form nor in its floor, nor in an absolute manner in any one of its external characters. "Its nature is in the pus which it secretes. Inoculation is the pathognomonic character of chancre, and which alone suffices to establish the diagnosis."* Here then is an infallible test of chancre—the nature of its pus, as manifested by its inherent power to reproduce a similar ulcer—offspring and parent being alike, if under the same constitutional influence; and the offspring—chancre—inherits the power of propagation. This method of diagnosis acquires a critical value from the fact esta- blished by Ricord, that the intensity of the constitutional manifestations about to ensue, cannot be measured by the number of chancres present simultaneously. Inoculation from a single chancre assuredly foretels any measure of constitutional perturbation ; it is the brand of syphilis. Then again, the power of reproduction is inborn in chancre, and avail- able, therefore, as the test of chancre from the very first formation of lymph, when the chancre is yet a vesicular or pustular pimple. Inocu- lation is the earliest, as well as the most infallible, criterion of chancre. Thus also it contrasts favourably with induration, which is otherwise the most characteristic symptom, but which, in Ricord's experience, never precedes the ulceration; that generally tOAvards the end of the first week following the infecting coitus, the induration manifests itself, and in the second week it becomes developed; but that while its development is rarely delayed until the third week, it is never met with earlier than the third day. The diagnostic advantage of inoculation, in point of timeli- ness, is apparently conceded by Mr. Lee ; Avho thus qualifies his otherAvise absolute rejection of this method of diagnosis. " A sore affected with the specific adhesive inflammation, will—he observes—yield a secretion capable of being inoculated during its earliest stage, before its specific * Op. cit. SYPHILIS. 179 action upon the patient's constitution has been developed, and the result of that inoculation may be a specific hardened sore accurately resem- bling the original. As soon as the specific adhesive inflammation has once taken place in a patient, his system is no longer in the same con- dition as before; he is no longer capable of being inoculated in the same way, and the inoculation, if attempted, in the vast majority of instances, entirely fails." The bearing of all these considerations, on the treatment of chancre in relation to the prevention of constitutional syphilis, is obvious, and will have its practical application when I come to that branch of the subject. What if this method of diagnosis, and the appropriate preventive treatment of constitutional syphilis, be postponed to a later period? Even then the open suppurating bubo, if present, is a chancre, and its pus Avill produce another chancre by inoculation. Not the pus secreted in the cellular tissue round about the suppurating gland, but that issuing from the gland. Here, then, is an additional test. We overtake the specific pus on its way to the blood, and possibly in time to anticipate its poisonous effects. Mere gonorrhoeal bubo, or sympathetic bubo, arising from any irritation, does not yield specific pus ; and the only question affecting the value of diagnosis by inoculation from bubo, is whether it affords a sufficiently early indication for the effectual employment of preventive measures. Ricord observed that bubo, however large, which has arisen from a chancre when about to heal, is simply a swelling of the gland, and fails to supply virulent matter. The poisonous pus hitherto secreted by the chancre, was transmitted quietly through the absorbing lymphatics, with- out occasioning any outbreak in the glands; and now that they do offer some resistance, as it were, the pus still transmitted from the chancre is no longer specific. But up to this time the chancre itself continues available for inocula- tion. The period of " statu quo specific" extends to when the ulcer cleanses itself, begins to throw out healthy granulations, and to cicatrize from its circumference. The duration of this period is considerable— frequently weeks, sometimes months ; as long, therefore, as a chancre can be expected to continue without the supervention of constitutional syphilis, rendering any anticipatory diagnosis useless. In August, 18G0, I had under my care a female patient in the Royal Free Hospital, Avho had previously an eruption on her skin, had then an ulcerated throat, and whose eyes presented, each, around the iris, a red zone bordering on iritis ; yet with this train of secondary symptoms, tAvo specific pus- secreting chancres still remained—one on either labium ; and these, the patient stated, she acquired in December, 1859 ! No other chancres were present, nor were there any vestiges of others having been; and indeed, judging from her course of life since the time mentioned, when she was received back to a respectable home, it is probable that no sexual inter- course has since taken place. On this assumption these tAvo chancres have continued specific during a period approaching eight months. Ricord maintains that the soft chancre, or that which he terms non-infecting, in a constitutional sense, mostly cicatrizes in the course of a few weeks; not unfrequently, however, the period of repair is prolonged much beyond ; and that this form of chancre persists in preserving its virulent specificity almost uo to the last moment of its existence; Avhile, indeed, cicatrization n 2 ISO GENERAL PATHOLOGY AND SURGERY. is proceeding at the circumference, the pus is specific in the centre of the ulcer ; on the other hand, " the infecting chancre once developed, is not slow to limit itself, rapidly attains the period of specific statu quo, and passes Avith equal rapidity to the period of cicatrization."* The case I have adduced is apparently one exception at least to the invariability of M. Ricord's dictum, and the records of other observers are, I think, opposed to it Of course the influence of different modes of therapeutic treatment must be taken into account; and of all differences in this respect affecting the results of statistics, the mercurial and non- mercurial treatment are the most influential. Subject thereto, I must alloAv that some of Rose'sf well-marked indurated, or infecting chancres of Ricord—which were treated without mercury—conformed to the law laid down by the latter authority ; they rapidly lost their specificity, for they rapidly healed. But such evidence of the short duration of the specific pus-forming power of this chancre is overruled by the history of thousands of other cases. Guthrie narrates cases treated without mercury, where the specific period, as measured by the chancre not healing, ex- tended over six, eight, ten, and in one case twenty-six weeks. To the same effect are the very numerous cases endorsed by Sir James M'Grigor and Sir William Franklin.J In 1940 chancres taken indiscriminately, and which healed without mercury, the average period was, without bubo, twenty-one days, with bubo, forty-five days ; and in 2827 chancres, in- cluding a larger proportion of indurated sores treated with mercury, the average period for healing was, without bubo, thirty-three days, with bubo, fifty days ; (being a difference, I may remark, adverse to the gene- rally supposed efficacy of mercurial treatment). During a long period, then, extending to weeks or months, chancre retains its specific pus-forming power; and co-extensive therewith the inoculation test is available, so as to authorize our employing preventive measures against Constitutional Syphilis further than by local treatment, which is successful only when used during the first four days after the birth of chancre. And the slow healing power of a supposed chancre is itself corroborative proof of its nature. This character—signified by the absence of granulations—was long since observed by Hunter, and recog- nised by Colles,§ as a prominent feature in his definition of true chancre. A self-reproducing and slow, perhaps very slow, healing sore or ulcer, is, in point of fact, a chancre; and while the latter character corroborates our exact diagnosis, it also provides a sufficiently early opportunity for the employment of certain preventive measures, after the first opportunity has passed away, in relation to Constitutional Syphilis. What its manifestations are, will next engage our attention. Constitutional or Secondary Syphilis. The blood, having become infected, after the appearance of induration, in the course of a month or six weeks, or a longer period, a constitutional disturbance—the syphilitic fever—ensues, usually in some degree. A dry, hot skin, and furred tongue, are succeeded by weakness and pain in different parts, with gradually the wan sallowness of syphilitic cachexia. But, with the accession of this fever, various inflammatory modifica- tions of nutrition occur, in a tolerably regular order, in different parts of * Op. cit, f Med.-Chir. Trans., vol. viii. p. 558. + Milit. Surg., Hennen, 2nd ed., p. 545. § Pract. Obs. on the Venereal Disease, 1837, p. 75. CONSTITUTIONAL OR SECONDARY SYPHILIS. 181 the body. As manifestations of the blood-disease in operation, they are " secondary" or even " tertiary" to the chancre and thence the bubo, Avhich, proceeding from the original source of infection, constitute " pri- mary " syphilis. The slow-healing power of the primary sore, and of an open bubo, somewhat suggest the prevailing character of these secondary manifesta- tions. From the first moment of the pus-forming pimple, the whole career of syphilis is one of disintegration of the tissues, with an abortive effort of the reparative power by plastic lymph-forming induration. Disintegration by desquamative or other destructive eruptions of the skin; disintegration, by corroding ulceration of the tonsils, tongue, lips, palate, and perhaps the nose; disintegration, by iritis, with molecular lymph; disintegration, by irreparable destruction of the texture of the testis; disintegration, by caries and necrosis. Premature baldness, fretting ulceration around the roots of the finger and toe-nails, and a wan cachectic pallor, bespeak the consummation of syphilitic decay. Comparing Secondary Syphilis in all these various forms, with similar diseases arising from other causes; their resemblance is often remarkable, and their appearances differ rather in degree than in kind. Probably, therefore, none of the manifestations of constitutional syphilis, secondary symptoms, are singly characteristic; but a concurrence—cotemporaneously or consecutively—of such symptoms, may be diagnostic. The descriptions given in Mr. Lee's elaborate treatise—for instance"— with regard to syphilitic eruptions, for the most part amply confirm this general proposition. (1) Skin-diseases.—Similar eruptions—exanthematous or rashes, pa- pular or pimples, tubercular, squamous or scaly, vesicular and pustular —arise alike, as manifestations of constitutional syphilis in the skin ; and also under other circumstances. Roseola or rose-rash.—The eruption which usually first succeeds the syphilitic fever, is of a rose-red colour, not raised above the surface of the skin, disappearing on pressure, and returning as soon as the pressure is removed. It arises in the form of more or less rounded patches, giving a mottled appearance to the skin; when examined closely, each patch is seen to be made up of a cluster of papillae, more injected than natural. This eruption sometimes vanishes within a few days. If it persists, the papillae forming each patch generally become visibly enlarged, and the colour of the eruption gradually changes to a copper hue. This colour is commonly present in all syphilitic eruptions Avhich remain for any length of time without suppuration or ulceration ; but it is not peculiar to (secondary) syphilitic eruptions, it is not pathognomonic. It is— observes Erasmus Wilson*—commonly met with in chronic eruptions of other kinds; for example, in acne, and non-syphilitic eruptions often possess more of the dull and muddy copper colour which is generally supposed to be characteristic of syphilis, than syphilitic eruptions them- selves. Moreover, when present in undoubtedly syphilitic skin-diseases, it does not supervene until their decline. The eruptions Avhich follow this first efflorescence on the skin, present a variety of appearances. Lichen, a papular eruption.—The papillae of the skin are enlarged separately, in the form of hard elevations having a copper-colour, which * Syphilis and Syphilitic Eruptions, 1852, pp. 60-64. 182 GENERAL PATHOLOGY AND SURGERY. terminate by desquamation or resolution. These elevations may be scat- tered irregularly over the body, or collected together into groups. Tubercular eruption.—Effusion of plastic lymph having taken place, it becomes organized, as in the papular eruption, but now in the form of small, and tense conical eminences, covered with a red shining cuticle ; Avhich gradually acquire a copper tint, and shed their shining silvery scales of cuticle. The tubercles may be scattered singly over the surface, or aggregated into groups. Lepra, a scaly eruption,. commences, like the mottled skin of roseola, by the injection of circular groups of papillae. The papillae are at first separate, but soon the whole circular patch becomes equally involved; an effusion takes place into the substance of the skin, which then presents a small flat elevation, the edges of which are sometimes raised higher than the centre. A copper colour, of a more or less decided hue, overspreads the eruption, but it is often partially masked by a thin layer of cuticle, which is shed in thin white shining scales, as in common lepra. Numerous patches, all perfectly circular, may form on any part of the body. Patches of syphilitic lepra sometimes much resemble flattened syphilitic tubercles. Psoriasis—another scaly eruption—occurs in the form of oval or irregular patches, slightly elevated above the surface. They are not de- pressed in the centre, and are often traversed by cracks or fissures. A copper or brown colour is often observable, but covered with epithelial scales of various degrees of thickness. This disease is much more per- sistent than syphilitic lepra. It occurs on the palms of the hands and soles of the feet, or on any part of the body. Vesicular eruptions—as manifestations of constitutional syphilis, are similar to, if not identical with, vesicular eruptions not of syphilitic origin. Thus, in point of their origin only, we recognise syphilitic herpes, eczema, and pemphigus or pompholyx. In all, an effusion of serous fluid raises the cuticle into vesicles, or blebs,—bullae, Avhich are simply large vesicles such as occur in the last named form of eruption. But the diag- nostic characters of syphilitic vesicular eruptions, are even less peculiar than those of the eruptions, already noticed. Pustular eruptions constitute also an analogous class to the non- syphilitic. They, like eruptions generally, may arise from the transfor- mation of other eruptions, in the course of syphilis. Thus, the papular may change into the vesicular, and this pass into pustular. The proper pustular eruptions of syphilitic origin, are divided by Cazenave,* into three kinds: (a) Psydraceous pustules, which are either small and narrow, or of large size, elevated, and round. They have a hard base, and are sur- rounded by a copper-coloured areola. The pustules are of a dull reddish hue, and are developed in successive crops ; presenting examples of the disease in its origin, maturity, and decline. Their progress is sIoav, and the accompanying inflammation moderate. In some cases, however, it destroys the true skin, and leaves a small, white, circular scar, depressed in the centre, and not larger than a pin's head. This form chiefly occurs on the face and forehead, where it somewhat resembles acne rosacea, but it may appear on every part of the surface. The pus- tules dry into a small greyish scab, which separating, may leave either a cicatrix or some injection of the skin. On the limbs, psydraceous pustules are of the size of a lentil, but * Diseases of the Skin. (Burgess.) CONSTITUTIONAL OR SECONDARY SYPHILIS. 183 slightly elevated above the surface, with a hard base ; and they contain a very small quantity of yellowish-white matter, which presents a strong contrast to the copper-coloured elevation on which it rests. They are not followed by ulcers; a thin scab forms on them, which is succeeded by a scar, or sometimes by a livid discoloration, or a small chronic indu- ration. (b) Impetigo, preceded by slight malaise.—This eruption commences Avith redness of the affected parts; then small collections of purulent matter form irregular shaped patches, more or less confluent, resting upon surfaces of a coppery-red colour, which are soon covered by scabs irregu- lar in shape, harder, darker coloured, and more adherent than those of non-syphilitic impetigo. Beneath these scabs are characteristic ulcera- tions, followed by scars, varying in shape and extent. This eruption more frequently occurs on the face, but it may affect any part of the sur- face. It sometimes appears on several parts simultaneously, but it has no tendency to spread. It is always secondary. (c) Ecthyma.—The pustules are still larger,—the size of a shilling, or more isolated, and few in. number; chiefly occurring on the limbs, and especially the legs. Commencing as large livid spots, the epidermis be- comes raised over a considerable portion of each spot, by a greyish, sero- purulent matter, Avhich increases slowly, and is always surrounded by a broad cojjper-coloured areola, unlike the violet-red of non-syphilitic ecthyma. After a feAv days, the pustules having broken, scabs form, which are of a circular shape, dark and hard ; gradually increasing in thickness they fissure at their edges, and are very adherent and persistent. On separating, they expose deep round ulcers, with sharp-cut hard margins of a purple colour, whilst the bottom is greyish. They luvve little ten- dency to enlarge. The scabs generally re-form, and repeatedly, until the ulcers heal; leaving circular and lasting cicatrices. This is the most common form of syphilitic pustular eruption, and that which usually occurs in new-born children. Here, the pustules are broad, superficial, flat, of an oval shape, and in great numbers ; the scabs are dark and thick, and conceal small ulcers underneath. The counte- nance of the patient has quite a peculiar appearance ; it is drawn in, and marked with numerous wrinkles, like that of an old person; the skin has an earthy hue, the body is emaciated, and exhales a most disagreeable odour. Ulceration of the Skin in constitutional syphilis, may be either a sequel of some form of eruption, or it may arise independently; the syphilitic blood-disease always predisposing to disintegration of texture. But the characters of the ulcers just formed can scarcely be regarded as peculiar to syphilis. Ulceration of the skin in connexion with disease of bone about the skull, is specially noticed by Mr. Lee, with reference to its apparent cause—irritation—rather than as arising from the direct in- fluence of the syphilitic poison. The importance of this diagnosis, in relation to the appropriate treatment, is obvious. (2) Diseases of Mucous Membranes.— Ulceration of the tonsils—" sore- throat"—ranks among the earlier and less equivocal secondary symptoms. The ulcer formed is excavated, with a sharp and prominent, not to say everted, margin. The bed of this ulcer is sloughy, the surrounding mucous membrane dusky red. But even these appearances are not cha- racteristic of syphilis, and original observers, such as Rose* and Carmi. * Med.-Chir. Trans., vol. iii. p. 421. 184 GENERAL PATHOLOGY AND SURGERY. chael* concur in mistrusting " the ulcerated sore-throat." Certainly, the excavated ulcer of Hunter is not consequent on the indurated chancre only; and we must acknowledge, with Carmichael, that affections of the throat are too indistinct to afford any certain diagnosis. Fissures of, and milky stains on, the tongue and inside the lips are more pathognomonic, but the former must be distinguished from those cracks which accompany irritable dyspepsia, and the latter—opaque white spots—resemble aphthous spots. More doubtful are mucous tubercles situated on various parts of the buccal mucous membrane, as the tongue, lips, palate and tonsils. These tubercles are of a whitish colour, and may be seen also on the skin, in the form of pale, soft little cushions, bedewed with mucus; the skin surrounding each tubercle appearing puckered around its margin. Such tubercles—condylomata—are commonly found in secondary syphilis, grouped around the anus or on the scrotum; also, fretting along the margin of the external labia in the female; perhaps on the perinaeum, inner aspect of the thighs, and on the groins. Sometimes these tuber- cles occur in the axillae (E. Wilson) ; and, in fact, wherever ordinary tubercles are warm and moist, they frequently become mucous tubercles, skin readily assuming the appearance of mucous membrane. But mucous tubercles are not necessarily syphilitic. Wilson noticesf the transition of roseola into lichen, of the roseola eruption into such tubercles, and that the conversion of lichen into them is by no means un- common ; yet roseola and lichen are not necessarily syphilitic eruptions. " Ulceration of the nasal mucous membrane, that of the hard and soft palate, of the pharynx opposite the mouth, and of the larynx," may ensue in secondary syphilis. These ulcerations are frequently accom- panied with caries of the nasal bones, of the hard palate, even the vertebrae behind the pharynx, and necrosis of the laryngeal cartilages. The breath and discharges are singularly foetid. Is any such ulceration peculiar to secondary syphilis ? CollesJ acknowledges his inability to de- termine whether an ulcer in the nose be venereal or not. The appear- ances of scrofulous ozaena closely resemble those of venereal ozaena. Colles describes an ulcerated opening situated on the septum nasi, about a quarter of an inch from its anterior extremity, this ulcer being uniformly circular, and as large as the surface of a split pea; but adds, that a similar aperture may be found in persons who certainly never had any venereal affection, and that it may remain for years, at least for eight or ten years, in cases under observation. Extensive ulceration of the pharynx, as well as ulceration of the nasal mucous membrane and caries of the nasal bones, Avere noticed by Carmichael to be frequently associated with the primary phagedaenic ulcer, but that similar ulceration of the pharynx arises in constitutional conditions assuredly not venereal Chronic laryngitis, and ulceration of the rima glottidis, denoted by a broken voice, impulsive cough and foul expectoration, may be a manifes- tation of advanced and grave secondary syphilis. Portions of the laryn- geal cartilages—e.g., the cornua of the thyroid cartilage, in an ossified state, are occasionally coughed up. Sir A. Cooper mentions these extreme cases, in his Lectures ; but syphilitic laryngitis presents nothing peculiar in its characters, from first to last, whereby it can be distinguished * Essay on Venereal Diseases, 1825, p. 64. f Op. cit. + Pract. Obs. on the Venereal Disease, 1837, pp. 305-316! CONSTITUTIONAL OR SECONDARY SYPHILIS. 185 from chronic laryngitis ensuing under other circumstances. The symp- toms just mentioned might follow laryngitis, from a common cold. (3) " Syphilitic iritis " was overlooked by Hunter, in his observations of the course of the venereal disease; but although undoubtedly a fre- quent form of secondary syphilis, it cannot be distinguished from arthritic iritis; and resembles scrofulous iritis, in so far as regards the appearance of the eye itself. An elaborate work,* which still retains its rank, states that in syphilitic iritis the eye presents tubercular depositions of lymph on the iris, a reddish-brown discoloration of the iris on its inner circle, and an angular disfiguration of the pupil, which is also occasionally displaced towards the root of the nose; and that these appearances, coupled with nocturnal exa- cerbations of pain, experienced in a much slighter degree, or not at all, during the day, are together sufficient to complete our diagnosis, corrobo- rated as it is by the previous occurrence of syphilis, and in most instances the concomitant existence of other syphilitic symptoms. I shall presently notice the diagnostic value of contemporaneous and consecutive symptoms, respecting secondary syphilis; but how far trustworthy are the objective symptoms afforded by those appearances which the eye itself presents ? The authority I have quoted himself retracts in part the diagnosis he has laid down ; for, says he, " although the effusion of reddish, brownish, or brownish-yellow lymph on the iris in the adult, clearly shows the case to be venereal, I have seen analogous appearances in several instances, both of young children and infants, in whom no suspicion of syphilis could be entertained." The symptom in question is not peculiar to syphilitic iritis. Nor is " displacement of the pupil upwards and inwards " a characteristic appearance. It has been seen, especially by Mackenzie,! in chronic rheumatic arthritis ; and still more frequently in scrofulous sclerotitis, without iritis. Moreover, it is present only occasionally in syphilitic iritis. This symptom, therefore, is inconstant as well as equivocal. Mackenzie mistrusts all the special symptoms accorded to syphilitic iritis, excepting the tawny or rusty colour of the iris near its pupillary edge, a condition present in most syphilitic cases, and almost exclusively in them alone. (4) Chronic enlargement of the testicle, occurs late, if at all, in the course of syphilis, and cannot be distinguished from scrofulous enlarge- ment of this organ. The physical characters which the testis assumes in these diseased conditions are very similar. In both cases, the enlarge- ment may commence in the epididymis—sometimes in syphilitic, generally in scrofulous disease. In both cases, this swelling subsequently engages portions of the testis itself, the intervening portions remaining free and healthy ; so that sometimes, by careful manipulation, nodules can be felt in the substance of the organ, through the tunica albuginea. At length the Avhole testicle becomes considerably enlarged, and feels hard and heavy. Then the scrotum may become inflamed and adherent, eventually undergoing ulceration, accompanied Avith protrusion of the testicle. In one such case, at the hospital, the Avhole scrotum Avas so much thickened and discoloured that I removed the testicle together with the portion of skin chiefly involved, rather than endeavour to save the organ by partial ex- cision. On section, the appearances Avere those of a scrofulous testis. The epididymis was filled Avith a yellow friable matter, which, under the * Diseases of the Eye, W. Lawrence, 2nd Edit., 1841, p. 428. t Diseases of the Eye, 4th edit., 1854, p. 543. 186 GENERAL PATHOLOGY AND SURGERY. microscope, was seen to consist of imperfect broken cells and granules; while nodules of this substance were deposited here and there throughout the testicle, itself otherwise healthy, the reddish-grey colour of its tubuli seminiferi contrasting with the yellow nodules. The man bore the mark as of a chancre at the corona glandis, which he says occurred about two years ago, and that the testicle began to enlarge nine months prior to the operation. Judging merely from the condition of the organ itself, in this case, it would have been almost impossible to have pronounced its enlargement syphilitic; and, indeed, the most accurate diagnosticians have acknowledged the resemblance of scrofulous and syphilitic disease of the testicle. Under whatever circumstances chronic enlargement of the testis takes place, the symptoms are precisely the same, observes Sir B. Brodie.* Dupuytren, also, was led to this conclusion by his obser- vations.y Simple glandular enlargement or hypertrophy, and atrophy, of the testicle, are also noticed by some authors. The absorbent glands, in various parts of the body, are liable to become enlarged, and indurated enlargement of those, especially on the occiput and back of the neck, is regarded by Ricord, I believe, as diagnostic of secondary syphilis. But this condition is attributed, by other writers, only to disease of the parts in communication with such glands. (5) Diseases of the bones, periosteum, fascia, and ligaments are possible manifestations of constitutional syphilis, advancing from the surface to deeper textures within the body ; but this is a neutral ground, shared by the mercurial poison—prolonged mercurialization, by scrofula also, and by rheumatism. The question of venereal origin is open, therefore, in every case, to investigation, probably, afterwards to doubt. A truly syphilitic node, for example, is usually considered to signify merely chronic enlargement of the bone itself. A hard swelling forms, without any redness of the skin in the first instance, nor subsequently for some time; eventually only it becomes red and acutely painful. Such nodes occur mostly in certain situations. The syphilitic virus appears to select certain bones or portions of bones for the production of nodes ; they are mostly subcutaneous, as the inner aspect of the shaft of the tibia, the subcutaneous portion of the ulna, the sternum, clavicle, and cranium. These portions of bone more especially form nodes, which become in- flamed. Nodes arising from periostitis are softer, and evidently inflamed from their commencement. They suddenly arise, and as suddenly sub- side. These distinctions are true, and yet the hard chronic node is no criterion of secondary syphilis. This kind of node seldom, if ever, appears, ex- cepting when mercury has been used, and coming, as it does, late in the career of syphilis, has perhaps been preceded by more than one salivation. Issuing from the mixture of mercury and syphilis, one cannot say how far a chronic node is due to one or the other. It is no sure indication of constitutional syphilis. Carmichael's experience' led him to regard this symptom as " equivocal and uncertain." Colles notices " a general nodose affection of the bones," Avhich is liable to be confounded Avith so-called syphilitic nodes, and he draws some distinctions.^ Caries and necrosis are no less doubtful evidence of constitutional syphilis. Spongy softening of the bones, denoting caries, may happen in * Lond. Med. Gazette, vol. xiii. p. 221. + Clin. Chi., t. i. p. 100. X Op. cit., p. 185. CONSTITUTIONAL OR SECONDARY SYPHILIS. 187 an advanced stage of secondary syphilis, and has its chosen seats; these being chiefly those where nodes are prone to form—on the tibia, ulna, clavicle, sternum, and above all, the nasal bones and cranium. But Avhatever bone or bones undergo carious softening, there is nothing characteristic of syphilis. Mercury as well as syphilis may be at Avork ; and indeed Ave rarely, if ever, find caries in syphilitic cases, excepting where mercury has been freely used. None of the cases of syphilis which came under the observation of Guthrie,* in the York Hospital, were accompanied with caries ; and such was also the experience of Rose, in his series of cases,f upwards of a hundred and tAventy in number, and where he was able to ascertain that the patients remained free from syphilis for many months afterwards, or if secondary symptoms returned, caries was not one of them. Necrosis, in constitutional syphilis, is equally often the offspring of mercury. Tertiary Symptoms.—All the foregoing diseases can scarcely be desig- nated secondary. Some of them, and more particularly disease of the testicle and of the bones, are tertiary, as compared with others previously described in the series. So also are certain ulcerations affecting the nose, lips, and roots of the nails. A tubercular nodule may form on the ala of the nose. It is a hardened copper-coloured mass, varying in size from the eighth of an inch and more ; persistent perhaps for many months, then ulcerating and destroying the nasal cartilages, and possibly extending further. Cracks on either lip may appear, and remaining for weeks or monthsv ulcerate extensively. Ulceration about the roots of the nails, onychia, may occur, having a broAvn or black colour, surrounded by a deep copper-red margin, and attended with a most offensive discharge. The ringers, toes, or both, though commonly the former, may be thus affected. In either case the ulceration is very obstinate, and the nails loosen, or fall off. The hair may become dry, Avithered, and faded in colour; cracked or split at its extremities, and be shed or easily combed off, abundantly, even to baldness. If the bulbs are affected, the hair is not reproduced, and the baldness is permanent, a condition known as alopecia. It may be partial or entire ; and affect the beard, eyebroAvs, and eyelashes. In one case, recorded by Vidal, the hair over the whole body came off. Syphilitic diseases of internal organs, apparently consisting of lymph- deposits, are, doubtless, highly important in the history of Constitutional Syphilis; but their diagnosis is mostly obscure, and needs much further clinical investigation. Lastly, a Avan, yelloAvish hue, overshadows the skin in an advanced stage of the disease, which is designated the syphilitic cachexia; but this may denote a mercurial deterioration of the blood. Hereditary, Congenital, Infantile Syphilis.—The term infantile syphilis is not intended to signify primary syphilis in an infant, commu- nicated at birth, from a primary sore or chancre existing in the person of the mother. The disease referred to is truly constitutional syphilis inborn, and transmitted as an hereditary infection, from the mother at the time of conception or during the period of intra-uterine life. But constitutional syphilis in the mother, in the father, or in both parents, is not necessarily transmitted to the offspring; who may indeed be singu- * Med.-Chir. Trans., vol. viii. p. 560. + Ibid., p. 422. 18S GENERAL PATHOLOGY AND SURGERY. larly free from any manifest constitutional syphilitic taint, or any other evidence of impaired constitutional vigour—as scrofula. Syphilitic infection of the ovum appears so to lower its vitality, as to entail many morbid consequences. Abortion may ensue, at a variable period of pregnancy, the ovum never reaching maturity. Several con- secutive miscarriages may thus take place, until the maternal or paternal state of infection is rectified or eradicated ; when the mother will probably retain the foetus for the full period of pregnancy—nine months, and then give birth to a living child. From the time of birth, the infant may exhibit symptoms of secondary syphilis, and present a cachectic, weakly, dAvindled, and as it were, aged appearance. Or, free from any secondary symptoms at birth, they supervene in a variable period—a few weeks, commonly between the third and eighth week—or, perhaps, not until adult age. The mode of communication would appear to take place in either of four ways, or in their combinations :—(1) From constitutional syphilis in the father, and without communicating any apparent infection to the mother; (2) from constitutional syphilis in the mother; (3) from both parents; (4) from systemic infection of the mother, through a primary sore—a chancre, contracted during pregnancy—the embryo having been quite healthy at the time of conception. The important relation of these modes of transmitting syphilis to offspring, will be obvious, both in regard to treatment and to medico- legal inquiry. Many other questions pertaining to hereditary syphilis, remain open to doubt, and are disputed. Firstly, whether a mother, pregnant with a syphilitic foetus, the offspring of a father having the constitutional disease, can be infected through it without herself having had primary syphilis ? Ricord ansAvers this question in the affirmative, and the possibility of this mode of maternal infection, is supported by a large amount of evidence collected by Mr. J. Hutchinson. Secondly, whether a wet-nurse, having the constitutional disease, can infect the child she suckles, through the medium of the milk ? Yes, says Ricord; no, says Acton. Thirdly, conversely, whether a syphilitic child can infect a healthy nurse? No, say Ricord and Acton. But Hunter and Lawrence relate cases in which several nurses have been thus infected, in succession; and two of Avhom transmitted the disease again to their own offspring. Evidence in sup- port of the affirmative of both the two latter questions, may be found in " Ranking's Half-yearly Abstract," vol. iv. As to the mode of communica- tion by suckling; any crack or abrasion on the nipple, or on the lip or mouth of the child, will facilitate the transmission. But, according to Dr. Colles, mere contact, without any excoriation, Avill suffice. Symptoms.—Hereditary syphilis is not indicated by any peculiar symptoms. The cachectic, wasted, condition of the child, usually attracts attention. Secondary symptoms are manifested by the skin, and mucous membranes—especially of the nose and mouth. Congestion of, and offen- sive muco-purulent discharge from the nasal mucous membrane, are accompanied with a puffed appearance of the nose, and constant snuffling breathing, as a chronic catarrh, existing from birth, or soon supervening. The mouth exhibits spots of ulceration. Cutaneous eruptions appear, before birth—the infant presenting some such eruption from birth, or not until some weeks have elapsed—usually three or four. It appears in certain parts, more particularly ; about the mouth, on the nates or CONSTITUTIONAL OR SECONDARY SYPHILIS. 189 scrotum, or on the soles of the feet. Hence, observation should always be directed to these parts, in examining an infant supposed to be the victim of hereditary syphilis. The eruption may be recognised in the form either of flat, squamous tubercles, associated with maculae or spots; or as vesicles or bullae, which dry into scales or scabs. A brownish-red, coppery colour, of, or around these eruptions, is more characteristic. The teeth, both temporary and permanent, are affected; the latter with a specific and peculiar appearance. According to Mr. J. Hutchinson's original observations, certain carious, or ill-developed appearances are presented. The temporary teeth are cut early, have a bad colour, and are liable to a crumbling decay. The upper central incisors usually undergo this destructive change early, and always first; then follow the lateral incisors, Avhich become carious and are shed ; lastly, though rarely, the canine teeth wear away, so as to assume a flattened, tusk-like character. OAving to early decay of the incisors, the syphilitic child remains edentulous from an early period, in regard to these teeth, and has a remarkably unsightly appearance in the laugh of childhood, until the permanent ones are cut. The permanent teeth, are more peculiarly affected ; chiefly the upper incisors, and first the central ones. They are discoloured, short, peggy, rounded at the angles ; standing apart with interspaces, or converging ; and marked, on their margin, with a deep broad notch. They readily disintegrate, crumble, and wear down. Vaccino-Syphilitic Inoculation.—A most important social question, is, whether a true chancre—an infecting syphilitic sore—can be commu- nicated by vaccination,—through the vaccine virus ? Dr. Viennois, in 1860, brought forward cases, apparently, of such syphilitic transmission; other cases subsequently occurred under M. Trousseau, in the Hotel Dieu; and, since, at RiAralta, an overwhelming demonstration occurred, one child, thus infected, having re-transmitted the disease to another child, and thence, through both, to forty-five other children, and to twenty other mothers or nurses! Diagnosis of Constitutional Syphilis.—The presence of constitu- tional syphilis, as manifested by secondary symptoms, is determined solely by the calculation of probabilities; and this is the basis of diagnosis in respect to all diseases, excepting the few that are absolutely determined by pathognomonic signs. The diagnostic value of any one symptom is represented by the constancy of its presence and association with the same disease, and by the early period of its occurrence. But the co-existence, or at least the consecutiveness, of symptoms, any one of which is equivocal, per se; constitutes a weight of evidence greater in the aggregate, than that which the several items of evidence Avould represent by being merely added together. To illustrate this force of concurrence, by the evidence of secondary symptoms, I shall pass over the order of priority of these symptoms; thus overlooking the relative value of each, as an early symptom. No one secondary symptom is sufficiently constant or peculiar to syphilis, to make their order of succession a question of much practical interest. But the fact of these symptoms being concurrent in the same person, outAveighs their inconstancy. Let the weight of anti syphilitic probability be represented by 5 ; then any one of the five usual secondary symptoms may be absent, or, if present, may point perhaps to constitu- tional syphilis, perhaps to the mercurial crasis, perhaps to both; perhaps 190 GENERAL PATHOLOGY AND SURGERY. to neither of these blood-diseases, but proceed from other causes. Thus, the skin-eruption having a coppery hue; the excavated ulcer of either or both tonsils; iritis; enlarged testicle ; node, caries, necrosis ; are severally equivocal symptoms of constitutional syphilis; but taken collectively, or at least as consecutive symptoms, they outweigh the supposed anti-syphilitic counterpoise. Constitutional syphilis is diagnosed by an overbalance of probabilities in its favour—this overbalance being due, not to the actual diagnostic value of each symptom or probability, but to their concurrence. In like manner, other circumstances may tend to corroborate our diag- nosis. The fact of primary syphilis, present or antecedent, has its Aveight— the weight of an additional probability, concurring. We look for the remains of a presumed chancre or chancres, and probably, also, the vestiges of a bubo or buboes. The diagnosis of constitutional syphilis—thus clearly illustrating the diagnostic value of concurrent symptoms—is the species of evidence on which rests the diagnosis of most other blood-diseases; and, indeed, of diseases generally, the evidence of which is symptomatic. The Blood-origin of symptoms, is established, in like manner, by concurrent evidence ; but all the characters of blood-disease [P. p. 276] are rarely combined, or at least not in the same degree. Blood-origin of Secondary Syphilis.—The evidence is, partly, the " number of textures '' affected with some form of mal-nutrition—as of the skin, mucous membrane, iris, periosteum, bone and testicle; partly, the " migratory" character of these local affections—from skin to mucous membrane, to the iris, thence to the testicle, or to periosteum and bone; and partly, the "symmetrical" character of some such local affections; occasionally also, their " serpiginous," or creeping nature, as phage- daenic ulcerations of syphilitic origin. But the last two characters would seem to indicate some determining power in the textures, respecting the particular locality and form in which a particular blood-disease shall manifest itself. Lastly, syphilis is capable of being propagated by " inoculation." Blood-pathology of Syphilis.—Constitutional Syphilis shares the ob- scurity of other blood-diseases with few exceptions. The microscope exhibits nothing remarkable; chemical analysis, at present, brings no- thing to light. The potent virus works unseen, being known only by the commotion it occasions. As when a diver has disappeared beneath the surface, we watch the troubled waters, without seeing his operations in the deep; likewise the syphilitic virus having dived into the blood, Ave know nothing of its doings there until it throws up some eruption on the skin or mucous membrane. Moreover, as the debris and bubbles thrown up by a diver cannot be distinguished from the commotion produced by some monster sporting in the deep; so also the scales and pustules of syphilis are subsequent and equivocal signs of the kind of poison at work. Meanwhile, its operation proceeds silently yet surely. The virus has not hitherto been detected in the blood; nor does inoculation with syphilitic blood manifest any characteristic results. Ricord failed to discover inoculable pus in the blood, even in veins nearest the chancre. MM. Ricord and Grassi first noticed " a decrease of the globular element in the blood of persons affected with syphilis arising from the simple or non- infecting chancre ;" and indurated chancre also is apparently followed by a diminished proportion of globules, while the albumen increases. Yet these changes are not remarkable; and to discover the. blood-condition CONSTITUTIONAL OR SECONDARY SYPHILIS. 191 which precedes the local manifestations of constitutional syphilis, is still "a consummation devoutly to be wished." Rational Preventive treatment would then, and only then, be possible and practicable. Causative relation of Local to Constitutional Syphilis; and the Unity or Duality of the Syphilitic Virus.—Of the various forms of Local Syphilis already described as Chancres, opinions differ respecting their causative relation to Constitutional Syphilis. It Avould be impossible within the limits of this part of the Avork, to discuss the evidence and arguments pertaining to this vexed question. Ricord and his school, maintain that only one form of local syphilis— the indurated chancre—is the source of systemic infection; that it is the infecting sore, and that it invariably produces constitutional syphilis. But that non-indurated or soft chancre, is always a local disease, and is never followed by secondary affections. Hence, indurated chancre is the only form of primary syphilis. On the other hand, other observers, scarcely less distinguished, maintain; that while the indurated chancre possesses the greater poAver of producing constitutional syphilis, and is thence the most frequent cause; yet that soft chancres may also occasionally have this causative relation. Hence, they also may be regarded as forms of primary syphilis. My own experience inclines to this latter vieAv of the relative infecting character of hard and soft chancres. Inoculation throws some light on this question. The general results of inoculation in regard to syphilis, may perhaps be stated as follows :— 1. That a chancre always produces a specific virus. 2. That all chancres—hard and soft—are capable of being propagated by inoculation. 3. That inoculation with the serum or lymph from an indurated sore will only produce a chancre, and that an indurated one, when the system is unaffected. During, therefore, only the earliest stage of such chancre— i.e., prior to induration, which may be regarded as the first secondary symptom. 4. That inoculation from an indurated sore —the system being un- affected—is invariably followed by secondary affections. 5. That inoculation from a soft chancre is less certainly productive of secondary affections. 6. Secondary syphilis may be propagated by inoculation. 7. But, that inoculation from secondary syphilis, is inoperative on the individual himself, or upon another individual having secondary syphilis. 8. That the secretion of other specific diseases existing in syphilitic subjects (including the specific syphilitic pustule, and the sores which result from it), have no poAver of imparting constitutional syphilis. (H. Lee.) 9. That the natural secretions of glands in syphilitic subjects, when those glands are not themselves specifically diseased, have no poAver of imparting constitutional syphilis. (H. Lee.)* If any of these propositions be erroneous, the error arises not simply from the difficulty inherent in the investigation of inoculation, but also from the difficulty of rightly estimating the mass of, apparently, contra- dictory evidence on this subject. The modus operandi of chancre in producing systemic infection, is doubtful. * Holmes's Surgery, 2nd Ed., 1870. 192 GENERAL PATHOLOGY AND SURGERY. The lymphatic or absorbent vessels were formerly regarded by Hunter, and his school, as the only medium of transmitting the syphilitic virus- Independently of the experimental facts adduced by Segalas and Magendie, in evidence of the veins also being absorbents; there are two general facts which, apparently, disprove the absorbent function of the lympha- tics, in the production of syphilitic systemic infection. (1) That in those cases in which the irritation of the lymphatics is greatest, and where, therefore, we have the best evidence that the morbid matter has entered them, there is very seldom any secondary syphilitic affection. (2) That the best marked cases of systemic infection are as rarely pre- ceded by any very evident signs of inflammation of the lymphatic glands. In the first class of cases, moreover, the progress of the syphilitic virus may be traced along the lymphatic vessels as far as the first lymphatic gland in their course, but never beyond. In any part of this course, the poison may be arrested and produce a hard knotted cord or round indura- tion, or even a fresh chancre ; but there is no proof that the virus is con- veyed unchanged through these glands; on the contrary, the vessels beyond are never affected, and bubo never forms in the glands next in order. Thus, chancre on the penis or vulva, induces bubo of the gland in the groin, above Poupart's ligament, but does not affect the vessels and glands within the abdomen ; chancre on the finger affects the gland on the inner side of the biceps muscle just above the elbow, but not the axillary glands. Duly weighing these facts, and the analogy of the syphilitic virus with other poisons, in producing systemic infection ; Mr. Lee is inclined to believe that the syphilitic virus is communicated directly to the blood, through the nutritive changes of the part around a chancre, or point of inoculation. Treatment.—Local Syphilis. (1) Chancre.—The earliest considera- tion, in the treatment of chancre, is the prevention of systemic infection; and the more so, since, in common with all blood-diseases, Syphilis is far more preventible than curable. Hence—observes Ricord—" the grand secret is, to reduce the specific ulceration to the state of a common ulcer, and to transform a wound possessing a special Arirus for its maintenance into one which no longer has such a resource." The earliest and most exact diagnosis of chancre, cannot, as we have seen, be determined by induration ; but inoculation supplies the requisite test of specificity. Moreover, in relation to the most effectual known preventive measures, induration—occurring about the end of the first Aveek, and never before the third day—supervenes too late for their effec- tive application. Escharotics, in Ricord's experience, are available within the first four days only, to prevent systemic infection,—you then kill the syphilis in its germ. Sigmund, of Vienna, also states as the result of his observation, in upwards of 1000 cases, extending over eleven years, that secondary manifestations never appear when the chancre is completely destroyed within the first four days. Cauterization to be thus effective, must be, not a slight superficial cauterization, which only destroys the surface of the ulcer, but a cauterization deep, broad, and destructive. We are dealing not merely with a poisoned wound, but with a self-producing poisoned wound. A paste consisting of sulphuric acid and charcoal, or stick nitrate of silver, will answer this purpose; but it must be applied over the whole sore and around, so as to include the infected peripheric zone of tissue beyond it. CONSTITUTIONAL OR SECONDARY SYPHILIS. 193 By such local treatment alone can the chancre be converted into a simple healing ulcer,—in time to prevent systemic infection ; and it is also the surest prophylactic socially,—by extinguishing the nuclei of contagion. But, for either preventive purpose, destruction must be accomplished Avithin the first four days after the birth of chancre. Excision of an in- durated chancre has, occasionally, been practised; but this method of removing the cause in operation, is like that by escharotics—too late when induration has taken place ; and excision offers no advantage over cauterization. As a public pre\-entive measure against the propagation of primary syphilitic infection, the " Contagious Diseases Act" for the periodic in- spection of different classes of the community, was recently instituted ;— a similar legislative enactment to that which is in operation in France. As might be anticipated with reference to a procedure of such nature; its expediency has been strenuously advocated from a sanitary point of view, and an extension of the Act urged, by numerous scientific supporters; and it has heen equally denounced, on moral and social grounds, by irre- concilable opponents. The Government has wisely declared its intention of abiding the result of the most complete inquiry. The curative local treatment of chancre,—as a specific sore, is best accomplished by mercury. It may be applied in the form of mercurial ointment, spread on lint, and laid on the sore ; or as a lotion,—the lotio nigra, consisting of calomel and lime water, in the proportions of gj to §vj ; or, by calomel fumigation, locally applied, as suggested by Mr. Lee. No other kind of special or specific treatment, is necessary with regard to chancre, than its early destruction, for the purpose of preventing sys- temic infection; or curative measures, subsequently. The various forms Avhich chancre may assume, as the inflamed or phagedaenic sores, are to be treated by the same measures which would be appropriate for similar ulcers otherAvise arising (2) Bubo.—No kind of special treatment is here indicated. If the bubo be an indolent, hard, swelling of one or more lymphatic glands, such as generally folloAvs a systemic infecting sore; no kind of preven- tive treatment will then be of any avail,—systemic infection having already taken place, and the bubo itself occasions little inconvenience; if the bubo has suppurated and become an abscess, it is to be treated accord- ing to the course and tendency of other abscesses, not of syphilitic origin, and any consequent ulcer, in like manner. Constitutional Syphilis.—Preventive treatment still claims our first consideration. After the limited period for the prevention of systemic infection, by the destruction of chancre, and before constitutional syphilis is manifested by any secondary symptom, there is yet an intervening period of blood-inoculation,—extending over about a month or six weeks, more or less, during which the development of constitutional syphilis may be intercepted. OtherAvise, the blood will assuredly declare its noxious influence on nutrition, in due time ; by some secondary disease of the skin, by sore throat, iritis, and so forth. The impending evil is sure to supervene, in some form, the storm is sure to burst. There follows the indurated or infecting chancre,—says Ricord—a blood diathe- sis pregnant Avith misfortunes and tempests. An infallible explosion of constitutional affections will ensue. But if some such manifestations are inevitable, in the natural course of systemic infection, all experience concurs, I believe, in the possibility o 194 GENERAL PATHOLOGY AND SURGERY. of averting them by medicinal intervention. By what particular pre- ventive measures ? Here opinions differ widely. Mercury has long been, and is still generally, credited with the most potent prophylactic influence. The symptoms of its protective opera- tion, constituting mercurialization, and the modes of administering mer- cury, will be noticed presently, in connexion with the curative efficacy of this medicinal agent. It appears indisputable ; that if mercury be not preventive of systemic infection, no other known medicinal agent pos- sesses such influence in any perceptible degree. The chief difficulty attending investigations, with reference to this question, is first to deter- mine the natural course of local syphilis, in its different forms,—whether or not systemic infection would assuredly supervene; and thus, with corresponding certainty, to estimate the positive and negative results of mercurialization, or of other supposed protective measures. Remedial Treatment.—Mercury holds the first place, and iodide of po- tassium the second, in the present anti-syphilitic materia medica. It would be impossible and useless to enumerate all the various remedies for constitutional syphilis, which have been tried and failed, more or less entirely. Such are sarsaparilla, guaiacum, opium, conium, juniper, sassafras, dulcamara. &c. Mercury seems to produce a systemic condition which is antagonistic to, and incompatible Avith, constitutional syphilis, in most of the forms of its manifestation. And, indeed, this positively remedial operation of mer- cury, is rendered equivocal, only by the fact, that the natural tendency of syphilis to recovery requires further clinical observation. The symptoms of the systemic influence of mercury, and of its sufficient operation remedially; are, a slight tenderness of the gums adjoining the teeth, with, perhaps, a slightly increased flow of saliva, foetor of the breath, and a coppery taste in the mouth. But this degree of salivation must be maintained, until any secondary symptoms, whether as regards the skin, the throat, or the eyes, has entirely subsided; including also indu- ration of the primary sore. Not until then can mercury be safely dis- continued, Avith a view to the non-recurrence of secondary symptoms. The administration of mercury is a matter of equal importance, and scarcely less so, the kind of mercurial preparations employed. It may be introduced into the system, through the gastro-intestinal mucous mem- brane, by pills or solution taken internally; or through the skin, by the rubbing in of ointment, inunction; or by exposure to vapour, fumigation,__ mercurial bath ; or, by inhalation. Blue-pill—pilula hydrargyri, from three to five grains, two or three times a day ; or calomel, a grain or more, in the form of a pill, and taken as often; have long been favourite forms of administering mercury. But these preparations are apt to produce irritation of the gastro-intes- tinal canal, and the liver, by their continued use,—occasioning bilious diarrhoea and sickness, long before their beneficial operation on the system can take place. Their introduction is, in fact, thus intercepted, and the mercury is said to " run off by the bowels." A small proportion of opium—say, a quarter of a grain, combined with each pill, will tend to make the blue-pill or calomel settle on the stomach. The iodide of mer- cury, combined with opium in the form of a pill, is the preparation which 13iave long been in the habit of prescribing. It is less irritating to the stomach, and equally remedial. The liquor hydrargyri bichloridi, in half drachm doses, more or less, is a convenient form of administering mer- CONSTITUTIONAL OR SECONDARY SYPHILIS. 195 cury internally -^ but I use it rather to sustain the systemic influence of the iodide. Mercurial inunction supplies a more sure method of affecting the system, without any collateral disturbance of the digestive organs. It consists in rubbing in a small quantity of some mercurial ointment on the inner or thin-skinned aspect of the thighs, every night. A drachm of the blue ointment unguentum hydrargyri, may be thus continued nightly, until the gums are touched, and the secondary symptoms evidently sub- siding. The ointment must be rubbed in until it disappears, and then the greasy surface should be left unwashed. This, however, is a laborious and dirty ordeal, an additional penalty for any one to pay besides having syphilis. Mercurial fumigation may be preferable as a more cleanly and equally efficacious mode of introducing mercury through the skin. It consists in exposing the surface of the body, enveloped in a blanket up to the chin, to the fumes of some mercurial powder, which is heated until it rises in the form of vapour, and which can be advantageously associated with steam, as a vapour bath. For this purpose, an apparatus has been con- trived by Messrs. Savigny. Or, a more ready contrivance, is a half brick, heated to a dull redness, on which the powder is placed, and set in a pan containing a little water. Calomel is the mercurial preparation generally employed; and fifteen or tAventy grains, the quantity usually sufficient, will undergo volatilization, entirely, in fifteen or twenty minutes. The patient is then put to bed, so that the particles of calomel shall not be wiped off the surface of the body. This mode of introducing mercury is highly recommended by Mr. Lee, who observes that in his ex- perience, neither of the other modes removes the symptoms so readily as calomel fumigation ; none is attended by so little mischief to the patient's constitution ; and none is followed so seldom by a relapse. He extends it, as I have already mentioned, to the local treatment of primary sores; and by means of a tube and mouth-piece, the vapour of calomel can be conveyed to the throat, for the treatment of secondary syphilitic ulcera- tion affecting that part. Mercurial inhalation can be administered by a simple and efficient form of inhaler, Avhich is easily constructed; a common earthen tea-pot, to the spout of Avhich is attached a tube of vulcanized india-rubber, about a foot long, and provided with a bone mouth-piece, in shape like the amber of a meerschaum pipe. A scruple of calomel is placed in the tea-pot, and the little hole in the lid Avhich allows the escape of steam, is stopped with a peg of tightly rolled paper,—better than wood which yields and loosens in driving it in. The pot thus equipped is ready for use. Resting on an iron tripod stand, the bottom of the pot is exposed to the flame of a spirit- lamp, placed sufficiently near, so that the flame shall expand under the whole bottom. In two or three minutes, the calomel begins to pass into vapour, and, the lid having been raised for a moment to ascertain that fact, the patient is told to inspire through the mouth-piece, at the same moment closing his nostrils between his thumb and fore-finger, then expire through the nostrils; and so on alternately, breathing in a naturally free and easy manner. After about ten or fifteen minutes, all the calomel will have been inhaled as vapour, save a small quantity Avhich adheres as a thin, white film to the interior of the pot and tube. In tAvo cases Avherein I have resorted to the inhalation of calomel- vapour for the treatment of secondary syphilis, with ulceration and 196 GENERAL PATHOLOGY AND SURGERY. sloughing of the throat, the tea-pot inhaler, I improvis§d, having been used, the following facts are Avorthy of notice for guidance in general. 1. In both cases, previous treatment by mercury, and iodide of potassium, administered by the mouth, had been tried, successively, and failed; and, in one case, it was impossible thus to continue the treat- ment, these medicinal agents being absolutely rejected by the stomach with nausea, and constantly recurring sickness. 2. The gradual process of inhalation,—ten or fifteen minutes, and the quantity used, tAventy grains. 3. Explosive coughingafter inhalation,—variable in period of sequence, in its degree, and duration, but subsiding spontaneously and permanently. This might be moderated by reducing the quantity of calomel to, say half—ten grains, Avhile the same beneficial influence might be gained by repeating the inhalation. 4. Slight salivation, in about forty-eight hours, and disappearance of the secondary symptoms; ulceration of the throat, especially. 5. Compared with mercurial inunction, and with the mercurial bath; the inhalation of calomel vapour, is more speedy and effectual, in its systemic influence, than the one, and far more so than the other. 6. As to safety; in one of the two cases, the patient died, some days after inhalation, from bronchitis and pneumonia, but the patient had a very feeble venous circulation, and his constitution had been worn out by an Indian climate, and great intemperance, more than by constitutional syphilis. In the other case, the pulmonic effect of inhalation was incon- siderable, and the process was repeated on four different occasions, with- out any danger. The balance of evidence, from these two cases, is therefore, in favour of inhalation; and, relatively also to mercurial inunction, and the mer- curial bath. Excessive mercurialization produces symptoms which it may be con- venient here to notice. They are; profuse salivation, swelling of the salivary glands, gums, tongue, and face, ulceration of the mucous mem- brane, loosening of the teeth and even necrosis of the jaws. Diarrhoea, Avith bilious evacuations. Certain varieties of skin diseases ;—e.g., mer- curial eczema. Periostitis and ostitis, otherwise than connected with the mouth. Loav fever with great prostration or mercurial erythism. Nervous affections ;—e.g., neuralgic pains, partial paralysis, or mercurial tremor, sometimes complete paralysis and death ; usually observed in those subject to the action of mercurial fumigation. Iodide of potassium.—Not to be trusted for the prevention of consti- tutional syphilis, ranks next to mercury as a curative agent; and especially in some forms of the disease, and in a certain constitutional condition, whether natural to the individual or morbid, where the action of mercury cannot be borne. It may be stated generally, that in the forms of skin-erup- tion accompanied with plastic induration, in the earlier period of consti- tutional syphilis, and in young and vigorous subjects, mercury is most curative; whereas, in pustular eruptions, enlargement of the testicle, periostitis and ostitis, and any tertiary affections, in the later periods of syphilis, and in debilitated, cachectic, subjects, iodide of potassium is the more remedial. But, perhaps, it may be added, that its effects are less permanent than those of mercury, and thus the disease is liable to recur. Iodide of potassium is given in doses, usually from three to five grains, thrice daily, and combined with cinchona bark, cascarilla, or other CONSTITUTIONAL OR SECONDARY SYPHILIS. 197 vegetable tonic; this adjunct generally being requisite under the cir- cumstances of suppuration or ulceration, wherein the iodide is prescribed. This medicinal agent was, I believe, originally brought into use for the treatment of constitutional syphilis, by Mr. Samuel Cooper, Mr. Morton, and other Surgeons at University College Hospital, about the time Avhen I was a Student in that Institution; and it has since found much favour with the Profession. I have prescribed it with marked advantage in some thousands of cases, principally at the Royal Free Hospital. Iodide of mercury has considerable repute with many continental surgeons; a grain being given in a pill three times a day, and gradually increased to three grains. Or, this combination may, probably, be effected in the system, by the concurrent administration of iodide of potassium or iodide of sodium, while mercury is introduced through the skin; thus obviating any irritation of the digestive organs which might be excited by giving the iodide of mercury itself. Sarsaparilla has fir less influence on constitutional syphilis than was formerly supposed, within my recollection. Its therapeutic value would seem to be restricted to the more asthenic or later secondary, and tertiary symptoms, and as occurring in debilitated subjects; the same circum- stances which render iodide of potassium preferable to mercury. Or, again, mercury having produced a new series of symptoms simulating the syphilitic, sarsaparilla will then be remedial; or it may come into use at a subsequent period, to remove the sequeloz of a mercurial course. Sarsa- parilla is thus, on the one hand, a substitute for iodide of potassium ; or, on the other hand, an anti-mercurial. The decoction is the preparation usually employed, but it must be concentrated, and drank freely ; in not less quantity than a wineglassful three times a day. It may be advan- tageously combined with iodide of potassium ; the two forming Avhat has been indefinitely named, an " alterative" mixture. Sarsaparilla has also a tonic influence, but less so than bark, and it is said to be diuretic and diaphoretic. This compound influence may give sarsaparilla an advan- tage over the more purely tonic operation of bark, when given in combi - nation with iodide of potassium. Guaiacum—another overrated medicine in relation to constitutional syphilis—is nevertheless, apparently, beneficial under similar circum- stances to those which render sarsaparilla—and iodide of potassium— preferable to mercury; particularly in secondary affections of the perios- teum or bone, and as occurring in cachectic subjects ; or it may be useful in clearing off the effects of mercury. The stimulant and diaphoretic actions of guaiacum may, perhaps, explain its therapeutic influence in the course of secondary syphilis, and as an anti-mercurial. It Avould be of little practical importance to enlarge this general view of the medicinal treatment pertaining to Syphilis. Excluding the many nostrums Avhich, from time to time, have had a temporary remedial reputation ; the details of the course of treatment, with reference to the various forms of skin eruption, and other secondary, and tertiary, syphilitic manifestations; can alone be taught at the bedside, or learnt by ex- perience. The pathology and treatment of Syphilis are thus summed up by Mr. Lee. There are four varieties of local syphilis, resulting from the inocula- tion of the syphilitic virus, which are quite distinct, although they may occasionally succeed each other. 198 CENERAL PATHOLOGY AND SURGERY. The first variety is accompanied by the adhesive inflammation, and produces a peculiar chronic enlargement of the inguinal glands, which does not involve the skin or the cellular membrane. This variety is followed by secondary symptoms, and requires, both in its primary and secondary forms, mercurial treatment. The second is accompanied by suppurative inflammation. It does not affect the inguinal glands. It is not followed by constitutional diseases, and requires merely local treatment. The third is accompanied by the ulcerative inflammation. It produces suppuration, generally of one inguinal gland only, which yields an inoculable secretion. It is not followed by constitutional syphilis, and may be treated by local means. The fourth is accompanied by mortification. It does not affect the inguinal glands, is not followed by constitutional symptoms, and requires only local treatment. Syphilization yet remains to be noticed. It is said to be the curative treatment of constitutional syphilis by repeated inoculation with the syphilitic virus, and for the prevention of its recurrence. Syphilization is also practised for the cure of primary ulcers, under the influence of which it is said they soon lose their hardness and begin to cicatrize. Buboes are thus affected beneficially. Vegetations remain uninfluenced. This method of treatment, originated by M. Auzias-Turenne, about 1845, and adopted by M. Sperino, is specially advocated by Professor Boeck, of Christiania, with reference to constitutional syphilis; and, in 1865, he visited this country to inculcate his views by practical illustra- tion in the Lock Hospital. The matter from a primary syphilitic ulcer, hard or soft, the former being preferable, or that from the artificial sore of a patient undergoing syphilization, is inoculated or introduced, in the same way as vaccine matter. To prevent large ulcers and cicatrices, the inoculations are commenced on the sides of the trunk. Three inocula- tions are made on each side. After three days, pustules will have formed, and from these, other inoculations are then made. This is repeated every third day, the matter being ahvays taken from the last pustules, until no further effect can be produced with this matter. Fresh matter is now introduced, from another patient; pustules ensue as from the matter first used, but the pustules and ulcers resulting from this second matter are not nearly so large as those originally produced. A third matter elicits pustules and ulcers yet smaller and fewer in number; until, ultimately, no matter applied to the sides will produce any specific effect. But, the arms and thighs are still susceptible to inoculation, either from fresh matter or from matter of the last pustule. The process is therefore noAv repeated on these parts in succession, until there also an immunity is obtained. Ordinarily, this occurs in from three to four months. The conclusions arrived at by Professor Bbeck are :— (1) That artificial chancres on the sides and on the arms are always smaller than those on the thighs, and the series of inoculations shorter. (2) By continued inoculation the ulcers always become less and less, until at last inoculation gives a perfectly negative result. (3) The inoculated individual grows insensible to one matter, but is still susceptible to another, yet in a lower degree; and again to a third matter, but in a still lower degree; and so on until no further effect is produced by any matter. (4) Immunity having been obtained on the sides and on the arms, it CONSTITUTIONAL OR SECONDARY SYPHILIS. 199 will still be possible to have rather a long series of inoculations on the thighs. All these phenomena are said to be constant; they do not occur in one individual and not in another ; they will always be presented. " We have here an invariable law of nature." A saturation of the system with syphilis—according to MM. Auzias- Turenne and Sperino—is thus established; a syphilitic diathesis—accord- ing to Dr. Boeck—which, when once established, cannot be increased or intensified by the further inoculation of virulent matter. But the con- tinued insertion of this matter, stimulates the disease and enables it to pass through its regular course ; thus completing the series of phenomena which follow systemic syphilitic infection, in a far shorter period than if left to itself, or subjected to any other method of treatment. Relapses and the occurrence of the so-called tertiary disease, are therefore rarely found after this curative treatment; whilst the continued introduction of syphilitic matter into the system, destroys, in a varying period of time, the susceptibility of the individual; ultimately producing a local as well as a general immunity to the disease, which constitutes its preventive treatment. Patients of all ages, even very young infants who are the subjects of hereditary disease, have undergone this course of treatment. In the latter, however, inoculations will frequently not take effect ; nor in persons with acquired constitutional syphilis, who, at the same time, are suffering from some acute or debilitating disease. But the latter adverse conditions are temporary, and immunity is generally obtained. Its duration in regard to the local action of the virus is limited, freedom from susceptibility to the production of chancre being gradually lost after the inoculations have been discontinued; but the systemic immunity con- tinues, and frequently throughout the life of the patient. These results have been attested, it is said, by some hundreds of cases. It is admitted, however, that the success of syphilization is very much modified by the fact of whether, or not, the patient had previously under- gone mercurial treatment. Dr. Boeck alleges that mercury interrupts and retards the natural course of syphilis, and that, in like manner, it interferes with its treatment by continued inoculation,—thus diminishing the curative efficacy of syphilization. It was at this stage of the inquiry more particularly, that syphilization Avas tested at the Lock Hospital, in 27 cases, under Dr. Boeck's imme- diate supervision. Mr. James R. Lane, and Mr. Gascoyen—the surgeons to that Institution—have supplied an elaborate Report* of these cases; which, while it contributed interesting particulars on points connected with the clinical history of syphilization, and indirectly with the pathology of Syphilis, condemns it as a method of treatment. On this aspect of the question, the report concludes:—"We are entirely in accord as to the practical bearings of Syphilization, and we are decidedly of opinion that it is not a treatment which can be recommended for adoption. We con- sider that, even if it could be admitted to possess all the advantages claimed for it by its advocates, its superiority over other modes of treat- ment or in many instances over no treatment at all, would not sufficiently compensate for its tediousness, its painfulness, and the life-long marking which it entails upon the patient. » Med.-Chir. Trans., 1867. 200 GENERAL PATHOLOGY AND SURGERY. " If Syphilization could be relied upon, after other treatment had failed, to control the severer forms of the disease, especially in its tertiary stage, or to prevent its hereditary transmission, the benefit derived would, without doubt, more than counterbalance these disadvantages; but un- fortunately these are precisely the cases in which it has admittedly the least influence." CHAPTER VIII. ERYSIPELAS. Erysipelas is a blood-disease, manifested by a peculiar inflamma- tion of the skin, and subcellular texture, possibly also of the mucous membrane; and of an infectious character. The latter element of this definition is disputed, and indeed open to doubt. Any such doubt, and disputation, seem to have arisen from one over- sight—that of associating erysipelas, as a peculiar inflammation of the skin and subcellular texture of the head and face only, with erysipelatous inflammation of the skin and subcellular texture of any other part of the body. The former is decidedly infectious; the latter, apart from co- operating causes, less decidedly so. Simple Erysipelas.—Commencing in the integuments of the head and face, simple erysipelas exhibits the following characteristic appearances :— On the nose, either cheek, the margin of either ear, or sometimes on one of the temples, a slight blush of redness becomes visible, accompanied with stiffness rather than swelling of the skin; which has lost only its wonted suppleness, and acquired a shiny roseate hue. A tingling, burning sensation also, rather than pain, is experienced, and hence the popular name of this inflammation—St. Anthony's Fire. The redness of erysipelas assumes different tints ; usually being more scarlet, rather than purple ; but of whatever tint it may be, it disappears entirely on pressure, and returns immediately the finger is withdrawn—so free and persistent is the determination of blood. The tension also of the skin is readily perceived on passing the finger from the sound to the inflamed part. An abrupt margin defines, this redness and this stiffness; both are circum- scribed by an irregular line. The inflammation, thus mapped out, spreads continuously : erysipelas is, par excellence, a " serpiginous " skin affection; and while it diverges, creeping like Avater spilt on an impervious surface, the skin becomes swollen, some serum is effused into the subcellular texture also, and this swelling is soft and diffused. Nature makes no adequate reparative effort to limit and circumscribe the serum with lymph. Serous effusion, there- fore, proceeds, and the swelling increases—so much so as to close the eye- lids, distend the cheeks, disfigure the features, and, at length, obliterate all traces of personal identification. " What great events from little causes spring :" that trifling red nose, and now this defaced visage. The turgid textures are tense and painful, although still a burning pain. Terminations.—At this stage of the inflammation its course is some- times arrested, the redness fades, the swelling subsides; and this termi- nation by resolution occurs with or without shedding of the cuticle. In many instances, hoAvever, the issue is less speedy. Serous effusion, having ERYSIPELAS. 20] continued for a period varying from twelve to thirty-six hours, elevates the cuticle into vesicles, or larger blebs, exactly like those which follow a burn or scald. These semi-transparent and yellowish, or sometimes livid blisters, soon burst, and discharging their contents—serum, pure or bloody—subside into thin incrustations. When, in the course of a few days, these peel off, they disclose the subjacent skin either in a sound state or beset with superficial ulcerations. In some instances the true skin is less spared. It has a reddish-brown or livid hue, and even gan- grene of the skin succeeds ; announced by great tension, heat, and acute pain. But this issue of erysipelas is rare, and generally fatal. Such are the origin, course, and terminations of simple erysipelas— an inflammation akin to erythema, and contrasting with the phlegmonous variety, in which the skin and subcellular texture are both the seat of inflammation; the latter tissue being more especially, but secondarily, engaged. Phlegmonous Erysipelas—and its Diagnostic characters.—The roseate hue, if it should appear in the first instance, is soon exchanged for a brownish or livid tint which mottles the skin. Simultaneously, the sub- cellular texture is gorged with serum, and presents a considerable SAvell- ing, which, however, readily pits on pressure with the finger. This osdematous swelling, of considerable size, and this purple shade of colour exhibited by the skin, contrast with the characters of simple erysipelas as it first appears. The burning pain also is more severe, and perhaps accompanied with throbbing. Otherwise the simple and phlegmonous varieties have points of resemblance. In both, the redness presents a defined margin ; in both, the inflammation extends itself continuously by creeping over the surface. But then again, in phlegmonous erysipelas, serous infiltration of the subcellular texture advances and deepens with alarming rapidity; and although itself diffused, the stuffed cushion of cellular tissue soon feels brawny. A few small vesicles only represent the overflow of serum under the cuticle; they do not reveal the perilous state of affairs beneath the skin. Terminations.—Burrowing suppuration and rapid sloughing threaten ; these dangers not being attended Avith increased tension, swelling, and pointing, as in phlegmonous inflammation ; on the contrary, rather Avith diminished tension, subsidence, and flaccidity. Such is the experience of LaAvrence,* and of another original observer of this disease. At that period, Avrites Dupuytren,t when phlyctenae have formed, and the cellular texture becomes thickened and indurated, the symptoms appear for tAvo, three, or four days to be stationary ; and an inexperienced surgeon is even led to hope for the resolution of the inflammation, while the danger is really urgent and suppuration already exists. This, then, is the critical period of phlegmonous erysipelas. If unchecked, the conclusion of its career is told in a few words. Very soon after this period of deceitful calm comes an outburst. A more livid hue overshadoAvs the integu- ments ; the skin melts away in patches, accompanied with a discharge of bloody sanious fluid, and the exposure of Avhite sloughs of cellular tissue, portions of which bulge here and there through apertures in the integu- ment. Sometimes this texture perishes extensively, but if partially spared, large sloughs of cellular tissue, resembling masses of soddened toAV, are eventually detached; Avhile the adjoining cellular texture is * Med.-Chir. Trans., vol. xiv. t Clin. Chir., t. ii. p. 311. 202 GENERAL PATHOLOGY AND SURGERY. drilled with small abscesses, or a profuse suppuration burrows wherever fluid can find its way—betAveen muscles, and possibly into a neighbouring joint. Thus all parts around become involved in the ravages of phleg- monous erysipelas. In one fatal case, under Dupuytren's observation, the whole leg was laid bare of skin and cellular tissue, exposing the tibia and patella. After prolonged suppuration and sloughing, those textures which do escape—the muscles, fasciae, tendons, and bones—are so agglu- tinated together as to seriously and permanently impair their uses in the animal economy. It will be readily imagined that Erysipelas may spread from the scalp and face, to the neck, thence to the thorax, and occasionally extend as far as the extremities; or it may begin in some other part than the head and face—such as the leg, sometimes the trunk. In whatever part of the body Erysipelas first shows itself, its characters and course are similar; but while fading in that portion of the skin where it first appeared, it travels to the neighbouring skin. The various stages of this inflamma- tion, therefore usually coexist in different parts of the skin; the portion last affected being red and swollen, another part vesicated, while others are undergoing desquamation. It seems unnecessary to add a third variety of Erysipelas—the " oede- matous " of some authors, for the phlegmonous variety is itself oedematous in one stage of its career. In both, a diffused infiltration of the sub- cutaneous cellular texture with serum is conspicuous, and the pitting of this oedema on pressure with the finger its most distinctive character. Phlegmonous inflammation contrasts with phlegmonous erysipelas in certain particulars, and which determine their diagnosis—a question of much importance. Circumscribed and limited infiltration of the subcu- taneous cellular texture with coagulating lymph, is the essential patho- logical condition peculiar to phlegmon. It is an inflammation of the cellular texture primarily, the skin being only secondarily involved ; whereas phlegmonous erysipelas selects, first, the skin, and then involves the subcellular tissue. Coagulating lymph, rather than serum, is effused in phlegmon; the consequent swelling is therefore circumscribed and limited, instead of being diffused and wide-spreading; it is also brawny in the first instance, that of phlegmonous erysipelas only becomes so gradually; lastly, respecting the issue of these two species of inflammation—that of erysipelas is prone to slough, while that of phlegmon is liable only to this termination. One word about a disputed matter: the liability of mucous mem- branes, as well as skin, to erysipelatous inflammation. This question is answered affirmatively by Stevenson, who gives a series of 21 cases,* and subsequently by Arnott in an elaborate paper, y The former describes an affection of the throat, characterized by a red or purplish blush of the velum pendulum and uvula, with very little tumefaction, but considerable pain in swallowing. Excoriation of the inflamed surface frequently occurs, and superficial ulceration. This inflammation is preceded by febrile symptoms, even in mild cases, and may occur before or after the skin affection; it may, indeed, constitute the whole attack of erysipelas, without that of the skin supervening. Other men of observation—Law- rence, for instance, with whom I am inclined to concur—do not acknow- Cases illustrating the contagiaus nature of erysipelas, and its connexion with a severe affection of the throat. Edin. Med.-Chir. Trans., vol. ii., 1826. t Lond. Med. and Physical Journ., vol. lvii., 1827. ERYSIPELAS. 203 ledge erysipelatous inflammation of any mucous membrane. But this is still an open question. Fever.—Erysipelas is not announced by any peculiar functional dis- turbances. They constitute a fever, and of the typhoid type. But, as Gregory observes, "there is nothing characteristic of approaching erysipelas, as contra-distinguished from any other kind of eruptive ailment." " The pulse is peculiarly quick and sharp at the onset of this fever." Erysipelas of the face is said to be preceded and accompanied by a fever, of which "a peculiar affection of the sensorium" is the prominent symptom; and the initiatory fever of idiopathic erysipelas, in every case, is said to be accompanied by " inflammation of the fauces." Both these statements are confirmed by Arnott, and the latter symptom—sore throat—is associated, in Sir Thomas Watson's experience, with erysipelas of the head and face. Blood-pathology.—Erysipelas has been thus examined, yet with little result. The blood is rich in fibrin, and poor in globules; but these alterations, together with others that occur, are common to all the phlegmasiae. They are not peculiar to erysipelas, and therefore not characteristic. The circumstances of therapeutic treatment, age, &c, seriously affect the results of any analysis obtained in respect of this, as well as of all blood-diseases. Blood-origin, and Infection.—Erysipelas may be caused by infection —i.e., it may be produced by inhalation from a person having the disease. But this mode of production is observed only in some cases. Of such, the following, from original authorities on this subject, are noteAvorthy. Certain cases reported by Dr. Wells* are much to the point. An elderly man was attacked with erysipelas of the face, and died in about a week from the time when Dr. Wells first saw him—viz., on the 8th of August. On the 19th of the following month an elderly woman, landlady of the house in Avhich the old man had been a lodger, came under the care of Dr. Wells, also with erysipelas of the face. On inquiry it was found that the old man's wife had been seized Avith erysipelas a few days after his decease, and had died in about a week. Another old woman who had nursed the landlady was also attacked with this disease and died. Lastly, a young man, nephew of the old man, was seized, shortly after visiting his uncle, and died in a few days. In this last case the probability of infec- tion having been the cause of erysipelas is obvious, and Avith some pro- bability the same mode of propagation may be inferred respecting the whole series of cases. For the report further states, that the landlady had been several times with the old man and his wife during their sick- ness, and that after their death she had removed some furniture from the room they had occupied to her own apartment. Cases of like import occurred in the practice of Dr. Wells's contemporaries—Mr. Whitfield, apothecary for very many years to St. Thomas's Hospital, Pitcairn, and Baillie, who made similar observations in St. George's Hospital during the years 1795-96. Many years afterwards, to show the growing im- pression in favour of this doctrine, I might refer to cases of infectious erysipelas, recorded severally by Dickson,f Blackett,| and Stevenson.§ Then Mr. Arnott|| took up the inquiry. He collected Avhat had been * Trans, of a Society for the Improvement of Med. and Chir. Knowledge, 1800, vol. ii. p. 214. t Med.-Chir. Journ., April, 1819, p. 615. X Med. and Physical Journ., April, 1826. § Edin. Med.-Chir. Trans., vol. ii., 1826. || London Med. and Physical Journ., 1827, vol. lvii. 201 GENERAL PATHOLOGY AND SURGERY. done by others, and added the results of his own observations. " In one family, the mother Avas first affected Avith inflammation of the pharynx, terminating in mortification. On her death the husband was attacked Avith inflammation of the throat and erysipelas of the face. As he re- covered, the daughter was similarly seized with inflammation of the pharynx and severe erysipelas." Five years prior to this Paper, although published subsequently, a series of observations yet more convincing, if possible, were made by Dr. Gibson.* For example, the infant son of a gentleman was seized with erysipelas on one foot. Afterwards, the mother became affected with erysipelas of the face and scalp. Then the nurse, who suckled the child, was attacked with symptoms of pneumonia. She was removed to her father's house, four miles off. He, who some days before her arrival had received a wound of the scalp, was now seized Avith erysipelas of the face and scalp, and died. Soon afterwards, a sister, living in the same cottage, had fever Avith sore throat, from which she slowly recovered. Two children, in the same house, were cut off with what appeared to be croup. Taking a fair estimate of all these cases, it Avill be obA'ious that those are most decisive where the persons who became affected reside 1 at some distance from the house in which erysipelas first manifested itself. Persons living together might possibly be subject to some endemic source of disease—as bad drainage, or insufficient ventilation. But if the fact of persons acquiring erysipelas, after associating with those who have this disease, is in favour of its propagation by infection; so also, when the source of contamination is removed, the disease should cease to spread. Of this the following is an illustration :—The wards of the Dublin Fever and Dysentery Hospital were large and extremely well ventilated. " On paying my daily visit," Avrites Dr. Brereton,f " I ob- served one of the patients, who had been admitted with fever some days previously, to be formidably attacked with erysipelas. On the following day I found the patient in the next bed seized with it. On the third day, two patients in the adjoining beds were similarly attacked. I then," continues Dr. Brereton, " became seriously of opinion that the disease was contagious, but resolved not to have those already affected removed until I had tried the result of another day. On the following morning, I found three more in like manner labouring under the disease; and Avhat made it more remarkable, they were all similarly attacked in the head and face. I had them immediately put into another ward, where there were no patients; they all recovered, and no more erysipelas afterwards appeared." In this series seven patients were attacked successively, but here the supposed cause being removed, its effect ceased. Respecting, then, the propagation of erysipelas by infection, we have the double test of causation fulfilled; the presence of erysipelas is at once followed by this disease in persons associating therewith, and, being with- drawn, the disease at once ceases to multiply. It has been affirmed by some men of observation that this laAV holds good only of erysipelas affecting the face and scalp. Arnott and Watson are of this opinion; but, restricting, as they do, their definition of this disease to its manifestation on the head and face, the law of infectious propagation becomes absolute. Other authorities, however—and the * Edin. Med.-Chir. Trans., vol. iii., 1829. t Dub. Journ. of Medical Science, vol. vi. p. 176. ERYSIPELAS. 205 m-ijority—who do not take this localized view of erysipelas, are inclined to acknoAvledge its propagation by infection. My own observation has not been sufficiently directed to this matter to warrant me in offering a decisive opinion ; further than this, I can throw into the scale my testi- mony as to the infectious character of facial erysipelas, and probably of every idiopathic manifestation of the disease on any part of the body. Are fomites capable of transmitting this disease? Yes, certainly. Among the earlier writers, Wells observed that a certain patient caught erysipelas in consequence of being laid in the unchanged bed of one who died of it. Similar instances have occurred in the experience of most practitioners, unless due precautions were taken to prevent this risk of infection. But the wards of an hospital may themselves become con- taminated, and communicate the disease on a larger scale. By Gibson's Report, already quoted, we learn that a woman, Avith erysipelas of the hand, having been admitted into the Montrose Infirmary, and the patients in either adjoining bed having become affected, the whole ward was then cleared out, cleansed, Avhitewashed and fumigated. " Yet when they were again placed in that ward the disease reappeared," and it became neces- sary to remove all the patients from this little infirmary, and to take every precaution ere the infection was eradicated. The contaminating power of fomites, in the shape of furniture, floors, &c, is evinced by the fact that dry rubbing instead of washing the floors of an hospital, or the decks of a ship, is the surest safeguard against this source of infection. But fomites of all kinds retain most tenaciously the poison of erysipelas ; and, indeed, Gregory is of opinion that this poison is banished with more difficulty than any other known miasm. The period of latency or incubation—varying in each kind of infectious disease—in erysipelas, extends from two to fourteen days ; and when developed, the infecting area is twenty to thirty feet. External causes.—Erysipelas acknowledges, apparently, a traumatic origin, in some instances. Hence, therefore, all kinds of wounds, injuries, surgical operations, and irritants—such as blisters, caustics, &c.—are accredited causes of this species of inflammation. Besides mechanical and chemical irritants, heat and cold may be accorded their share of im- portance. Predisposing catises.—Any external cause may be reinforced, at least, by conditions within the body; resulting mostly from previous habits of intemperance, previous hardships, or both, perhaps also from mental de- pression—circumstances which have depraved the blood and enfeebled its circulation. But the disease is also most prevalent in spring and autumn, or at least Avhen hot and cold wet weather alternate ; and if period of the year has some predisposing influence, so also has the period of life, they being most liable who are old in years, or old for their years. Apart from predisposing causes, erysipelas, probably, would not arise; with their concurrence the scratch of a pin only may be apparently the traumatic origin of this disease. YTet even in such cases its infectious character becomes developed. In one instance, noticed by Lawrence,* erysipelas of the head and face, consequent on the insertion of a seton in the neck, was the only presumptive cause of this affection in two other persons. Travers,f indeed, goes so far as to affirm that he has repeatedly seen the " idiopathic'' arising from the " traumatic," or this from the former, and either from its OAvn source. * Op. cit. t Constitutional Irritation. Further Inquiry, 1835, p. 149. 206 GENERAL PATHOLOGY AND SURGERY. Lastly, the possibility of erysipelas arising spontaneously—that is to say, in an individual without any assignable external cause, and therefore without infection—is, I think, indisputable. The recurrence of this disease in the same individual is possible. I can speak from my own personal experience, having had it four times severely, in my head and face, when from nine to thirteen years of age. I was then a pupil at the King's College School, and although many years have elapsed, I well remember the flaming pain, and that my face was like a distended bladder. I just mention these particulars to verify so early a reminiscence in evidence of" an important fact, that susceptibility to true erysipelas—i.e., affecting the head and face—is not exhausted by one attack. Unlike most eruptive fevers, the blood does not lose its capability of undergoing this infection, again and again. Treatment.—Preventive measures must have reference to the causes of this disease. Its propagation by infection suggests the prompt isolation of any person having erysipelas—as the source of infection, free ventilation of the apartment, and the separate use of any bedding or other infected article, which might act as a fomes in carrying the disease to other patients. Dry-scrubbing instead of washing the floor of the bedroom or ward, has already been alluded to as a safeguard ; evaporations favouring, apparently, the dissemination of the infected atmosphere. Cleanliness with regard to the dressings used for other patients, and on the part of the nurses, is an obvious injunction. With all these precautions, a nurse or the practitioner himself may yet be the medium of communicating the disease. Disinfectants, such as chlorine vapour, or chlorinated solutions, permanganate of potash, and carbolic acid lotions, have more or less influence in purifying a contaminated atmosphere, or in guarding the wounds of patients who may be exposed to its operation. These preventive measures are less urgent with reference to erysipelas of traumatic origin. Predisposing causes, pertaining as they do mostly to the previous health of the individual, scarcely admit of prevention. They suggest, however, the greater protection of persons thus liable to infection. Such are persons whose blood has been depraved, and circulation enfeebled, by previous habits of intemperance, and by the wear and tear of a laborious, anxious life. Albuminuria is peculiarly inviting to erysipelas. Diabetic patients also are said to be liable. Remedial treatment—so-called—is a misnomer; for, like all infectious diseases, erysipelas runs a certain natural course, and the only poAver of art is to avert any unfavourable tendency. It is probable that a blood- poison is undergoing elimination from the system, through the great secreting surfaces—the skin, thus inducing the inflammation, and the mucous membranes. Consequently, the bowels having been evacuated by a mercurial and rhubarb or colocynth pill, a saline aperient, diuretic and diaphoretic mixture, may then be given Avith advantage for some days. Thus, the sulphate of magnesia, with nitrate of potash and small doses of tartarized antimony, seem to promote elimination. The acetate or car- bonate of ammonia, in camphor mixture, will be more specially diapho- retic. Bicarbonate of potash, in large doses, say half a drachm, has sometimes appeared to me, to fulfil a special purpose, that of neutralizing the blood-poison, whatever it be. Erysipelas is, I think, thus allied to rheumatism or rheumatic gout, to erythema and urticaria; in all of which diseases potash has some peculiar remedial influence. And in harmony ERYSIPELAS. 207 with their therapeutic affinity, I have observed clinically, that the same individuals are not unfrequently subject to each of these diseases. A dusky yellow hue of the skin, and slight yellowness of the conjunctiva, with perhaps nausea and oppression of the stomach are often present in erysipelas. This condition, verging on jaundice, is best overcome by the repeated administration of calomel or blue pill, to restore the secretion of bile. A blister over the region of the liver, is also, I believe, recom- mended by Mr. Syme. These measures are apparently more efficacious than the ipecacuanha emetic usually ordered to empty the stomach. The saline plan of treatment will, generally, prove sufficiently deple- tory—as well as excretory—without having recourse to blood-letting, to however small an amount. Debility, and the increasingly typhoid character of the fever, from the commencement of the disease, soon indicate the necessity for the substitution of a stimulant and tonic treat- ment. Carbonate of ammonia, in five or ten-grain doses, with disulphate of quina, in similar or even larger doses, may be given every four hours. Tincture of the sequichloride of iron, from ten to twenty minims every two hours, is highly extolled by Dr. Balfour—as a certain and unfailing remedy, whether the erysipelas be infantile or adult, idiopathic or traumatic. The diet must correspond to this medicinal treatment. Wine should be given, tolerably freely, in all cases, and even from the very beginning. Brandy and egg beat up together, form a convenient and agreeable mix- ture, at once stimulating and nourishing. Beef-tea and the other prepa- rations of nutritious and easily assimilated food, represent the general character of our dietetic resources. Noav, the degree to which this depletory, or stimulant and tonic, plan of treatment should be pushed, will vary with the symptoms, as they are more those of inflammatory or of typhoid fever. As the pulse becomes feeble and rapid, the tongue coated with a brown fur, and increasing debility supervenes; so must the one treatment be exchanged for the other. It is thus that the phlegmonous variety of erysipelas may, in the first instance, require more active depletory measures—purgative, diaphoretic, and diuretic salines, with antimony, in doses to touch the pulse, and the occasional use of blue-pill or calomel, in slightly cholagogue doses; but these measures must soon be exchanged for a yet more- free administration of quina with carbonate of ammonia, and a more supporting diet also, than in simple erysipelas. And again, erysipelas of traumatic origin may need yet further sup- port, in proportion to the severity of the injury conjoined with the erysipelas. Local Treatment.—Any repressive application Avould be obnoxious; not only as tending to divert the natural course of the disease, in the elimination of the blood-poison, but as possibly repelling the inflammation to some other part, its migration or metastasis being perilous and pro- longing the disease. In both these respects, the cutaneous inflammation of erysipelas is analogous to an attack of gout. Warm fomentations by spongio-piline or flannel steeped in a hot decoction of poppy-heads or chamomile flowers, and continuously applied, will hasten the termination of the inflammation by resolution. These epithems are also more soothing to the patient than dredging the part with flour or magnesia; a dirty, encrusting, and irritating application 208 GENERAL PATHOLOGY AND SURGERY. formerly in vogue, and still recommended by some authorities. Nor can much be said in favour of a strong solution of nitrate of silver, as an ap- plication to the inflamed surface ; which, if it fail by its astringent action to induce resolution, may, by over-stimulation, provoke sloughing. A circumferential line drawn with the nitrate of silver, strongly pencilled, Avas recommended by the late Dr. A. T. Thomson, for the purpose of setting up a sort of incompatible inflammation, and thus arresting the progress of the erysipelas. But this boundary rarely, if ever, proves a barrier ; such at least is the result of general experience; and I now never have recourse to the nitrate of silver in either of these ways. Phlegmonous erysipelas presents nothing peculiar, otherwise than as pertaining to the subcutaneous cellular texture, which, with the skin, is invariably although secondarily involved. Free incisions, and at an early period, therefore, fulfil a twofold purpose. By relieving tension, they may be preservative of the skin, and perhaps of the subcellular texture ; both of which are so apt to slough extensively. Moreover, pain is thus relieved, and the inflammation itself moderated by a discharge of blood with the serum effused. It is, indeed, remarkable to notice how the skin speedily loses its purple hue, and becomes almost blanched, as the engorged vessels bleed freely; the patient acknowledging a propor- tionate mitigation of the pain previously endured. Incisions also facilitate the discharge of pus and sloughs, which to some extent are inevitable. The preventive and curative efficacy of this treatment is now generally admitted ; but the number, length, and depth of the incisions, are particu- lars about which differences of opinion exist. Some surgeons prefer one long incision, a practice, however, fraught with probably more danger from shock and haemorrhage, while it is certainly less effectual for the relief of tension than incisions in different parts. A few cuts—three or four, and of as many inches in length, will be sufficient in most cases. In no case, need they be carried deeper than into the subcutaneous slough, which is easily recognised by its ash-grey colour. The treatment subsequently is similar to that of any other suppurating and sloughing wound. CHAPTER IX. PYAEMIA, OR PURULENT INFECTION. The term Pyaemia literally signifies Pus in the Blood (ttvov pus, cuua blood), or purulent infection of the blood ; a systemic condition arising most commonly, or which was first observed, in connexion with the local condition known as suppurative phlebitis; and which is, generally, soon followed by the formation of secondary abscesses, or at least by collec- tions of matter—secondary to the primary disease, and which are dis- tributed in various remote organs and parts of the body. But, in addition to this dependent series of affections, Pyaemia has more recently acquired a more comprehensive, and less definite, pathological significa- tion ; as representing, also, the systemic infection which arises from the introduction into the blood of animal or septic matter. Two, or more, kinds of systemic infection would thus be associated ; allied in their nature, probably. It, however, seems desirable, for the PYAEMIA, OR PURULENT INFECTION. 209 sake of accuracy and clearness of description, to dissociate them; and first, to restrict the term Pyaemia to its originally definite etymological meaning—purulent infection, and as arising, for example, from an ordi- nary suppurating wound; and then, give it its enlarged signification, as in connexion with poisoned wounds—for example, dissection-wound. Pyemia.—Symptoms.—A wound suddenly ceases to secrete and dis- charge pus—becoming drier or glazed; this morbid change is followed by concussive rigors, more or less violent, and in duration lasting for a few moments or for some minutes; then prostration; the face looks haggard, vacant, and alarmed, as if the individual were conscious of some vital injury—the nervo-muscular system responding by a prolonged shudder. This is not necessarily accompanied with a sensation of cOld. Rapid sighing completes the picture of prostration. At length the heart arouses, and the pulse rises, perhaps to 150 in a minute, beating feebly and irregularly ; soon a scorching heat of skin is experienced; flooding perspiration succeeds. The paroxysm is over. Similar paroxysms may recur at periods varying from twelve to thirty-six hours ;* or at about the same hour for three or four days; or at irregular intervals.-)- Probably, in most cases, rigors occur once for all, then absolute prostra- tion, from which no perceptible reaction ensues. Whether prostration be continued, or relieved by fits of reaction, other significant symptoms supervene. The skin becomes overcast with a dirty yellow tinge, and the abdomen tympanitic. All the secretions show signs of a blood-poison being ineffectually eliminated. Rank perspiration, often profuse, ammo- niacal urine, and a putrid diarrhoea, alike compete incessantly to evacuate it; but these drains only help to complete the exhaustion. The breath has been noticed by Berard and Mr. Gamgee to haAre a very peculiar odour, compared by the latter to that of sweetish liver or of new hay. In one well-marked case of pyaemia this odour was absent; and it was present without pyaemia in two other cases—one of prostatic abscess, the other, extravasation of urine after lithotrity. The diagnostic value of this symptom is therefore equivocal. Eventually the tongue and perhaps the lips are dry and brown, or black. Sometimes a leaden hue over- spreads the face (Gamgee). No time is allowed for progressive emaciation, as with hectic, prostration is so overwhelming : " the life of all his blood Is touched corruptibly ; and the pure brain (Which some suppose the soul's frail dwelling-house) Doth, by the idle comments that it makes, Foretell the ending of mortality." Pyaemia is not always fatal. Sedillott. and Vidal§ have recorded cases of recovery. Nelaton|| dissents, and affirms that death is inevitable. It takes place usually about the tenth day; sometimes earlier, as the third day, or, much later—six or seven weeks. Secondary Abscesses.—Post-mortem examination reveals numerous abscesses in one or more organs and textures of the body; and they are not inaptly termed secondary, because subsequent to an abscess, or at least to suppuration, in some other part. Secondary abscesses most * On Pyaemia, J. S. Gamgee, 1853. t Inflammation of the Veins, &c, H. Lee, 1850, Case xxxvii. X De Tlnfection Purulente, ou Pyemie, 1849. § Traite de Pathologic || Ele"mens de Pathologie Chirurgicale, p. 167. P 210 GENERAL PATHOLOGY AND SURGERY. frequently occur in the lungs and liver. Their general characters are these:—In several portions of the organ affected, black blood has accu- mulated ; such portions are indurated, but brittle and easily break down under slight pressure with the finger;—the texture is congested and disintegrated. Some of these disintegrated portions present a yellow spot of pus in the centre of the black mass; in other parts pus has altogether supplanted the blood and disintegrated textures ; and these pus-deposits are tolerably circumscribed ; in fact, abscesses are formed, each surrounded with a dark margin of congested texture. Mr. Lee* states that the central spot of each affected portion at first consists of lymph, which gradually extends towards the circumference. If the disease continue, these spots suppurate, the affected portions having previously softened and disintegrated in the same order in which they were primarily solidified. Secondary abscesses are usually of a small size, in the viscera varying from a pin's head to a walnut, very numerous, and of rapid for- mation, a few days sufficing for their development in many organs. Although most commonly found in the lungs and liver, other organs and tissues are not exempt. They occur elsewhere—approaching the follow- ing order of frequency—in the spleen, brain, kidneys, heart, skin, mucous membranes, within serous and synovial cavities, in the muscles and cellular tissue, and in the eye; in the prostate (Gamgee). The diagnosis from primary abscess is twofold. It will be observed, that the chosen seat of an ordinary or primary abscess—the cellular tex- ture—is not the usual habitation of secondary abscesses; and usually there are no local symptoms—no pain, or functional derangement, although certain parts—as the lung, pleura, peritoneum, and intestinal canal—will not tolerate secondary abscesses without some local symptoms of disaffection. It may also come to pass, that death ensues from coma, asphyxia, or from necraemia as the result of further blood- poisoning accruing from the non-elimination of various excrementitious matters. The blood itself has undergone serious changes of chemical composi- tion, probably; of physical properties and vital endowments, certainly. It has less plastic poAver, coagulates imperfectly and less readily. Hence, the more fluid blood is apt to transude, minute haemorrhages take place in various textures, and the gastro-intestinal mucous membrane is stained with a reddish tint. Pathology of Pyamia.—Having stated the leading facts relative to pyaemia as at present known, and its local consequences; to what theory or explanation do they point ? I have just alluded to certain changes Avhich pyaemic blood is found to have undergone after death. Now, the circumstances under which pyaemia arises lead to the inference that during life^ws itself, as bond fide pus, has entered the circulation, either by sup- purative inflammation of the veins—occasionally of the lymphatics, rarely of the arteries; or by absorption through the veins, aided by the lym- phatics, laid open and exposed by mechanical injury, as by wounds, or rapid sloughing of the suppurating part: and that the pus thus produced within vessels, or introduced from without, possibly circulates with the blood, inducing secondary deposits. Each clause of this sentence must be submitted to the test of clinical observation. (1) Suppurative Phlebitis.—Without doubt, suppurative inflammation * Op. cit., p. 52. PWEMIA, OR PURULENT INFECTION. 211 of a vein induces pyaemia, and thence secondary abscesses. Hunter* originally observed, that " in all cases Avhere inflammation of veins runs high, or extends itself considerably, it is to be expected that the whole system will be affected. For the most part, the same kind of affection takes place which arises from other inflammations, with this exception, that Avhere no adhesions of the sides of the vein are formed, or where such adhesions are incomplete, pus, passing into the circulation, may add to the general disorder, and even render it fatal." All subsequent observers have confirmed Hunter's observation as to the fact that suppurative phlebitis is frequently followed by pyaemia; some, moreover, have adopted his theory, that pus entering the circulation is the immediate cause, and have extended this view to interpret the for- mation of secondary abscesses; while no one, in my opinion, has ever disproved it. In 1815 Hodgson j supported the Hunterian theory of pyaemia; and although TraversJ alleged that suppurative phlebitis was compara- tiA-ely harmless, and the adhesive fatal; yet the influence of his opinion Avas soon reversed, the potency of pus-forming phlebitis re-acknowledged, and Hunter's theory re-adopted. Carmichael,§ contributed his observa- tions and his concurrence with this interpretation of pyaemia. Aber- nethy|| followed, rather as a disciple than as an original observer, in this department of Pathology. Then the French school instituted investiga- tions to discover the immediate cause of pyaemia from suppurative phle- bitis. Their results were, with scarcely an exception, in favour of Hunter's suggestion. Bouillaud^f contributed his clinical researches, ascribing the constitutional consequence of phlebitis to pus in the blood. Cruveilhier** likewise came to the conclusion, that pus is transmitted from the veins in which it is formed; and his observations of the stages of suppurative phlebitis tend to establish two facts. Firstly, when pus pro- duced within a vein is excluded from the general circulation, as by a barrier of coagulated blood, or by adhesion and obliteration of the vein, no symptoms of pyaemia ensue; secondly, when the obstruction is removed, the symptoms of pyaemia immediately commence. The unavoid- able inference is, that pus is carried from within the suppurating vein into the general circulation. It would appear that pus is first formed, not between the vein and the clot, but in the very centre of the coagulum, which soon blocks up an inflamed vein. The symptoms of pyaemia do not arise then ; but the pro- portion of coagulum diminishes, while that of the pus increases, and this may take place here and there in the course of the vein, as the inflam- mation is more or less advanced, thus presenting adhesive, alternating Avith suppurative, phlebitis. Usually, adhesive phlebitis limits and cir- cumscribes the suppuration; and then, also, the general mass of blood * Trans, of a Soc. for the Improvement of Med. and Chir. Knowledge, 1793, vol. i. p. IS. t Diseases of Arteries and Veins, 1815, pp. 511 and 518. X Wounds and Ligatures of Veins. Surg. Essays, Cooper and Travers, 3rd Edit., 1818, vol. i. p. 286. § Obs. on Varix and Venous Inflammation. Trans, of King's and Queen's Coll. of Phys., Ireland, 1818, vol. ii. pp. 355 and 368. || Essay on the Occasional Ill-consequences of Venesection. Surg. Works, 1823, vol. ii. p. 150. % Recherches Cliniques pour servir a 1 Histoire de la Phle'bite : Revue Me"d., Juin 1825, p. 424. ** Anatomie Pathologique, 1829-35, tome premier, liv. xi., Phle'bite et Abces VisceYaux • also Diet, de Me"d. et de Chir. Pratiques, art. Phle'bite. P 2 212 GENERAL PATHOLOGY AND SURGERY. remains uncontaminated.* Pyaemia does not arise under these circum- stances. As phlebitis advances, the distended vein becomes knotty at the various portions where pus has accumulated; eventually the vein bursts, pus is deposited in the surrounding cellular tissue, and abscesses are formed. Pending this issue, when the dyke made by the clots is broken, and removed by absorption, typhoid symptoms immediately com- mence, announced by violent rigors, soon succeeded by death. Fre- quently a patient, who overnight exhibited no constitutional symptoms of pyaemia, is found next morning in a dying state, and perhaps almost the moment when pus entered the circulation can be noted. Duly considering these facts, it is scarcely necessary to bring forward the corroborative testimony of other observers. Dancef and Blandin,| both attributed pyaemia to the transmission of pus from suppurating veins. Mr. Arnott,§ also was led by his observations of pyaemia in seventeen cases, cases of fatal phlebitis, to conclude that the entrance of pus into the circulation is its principal cause, " a similar influence being, perhaps, also possessed by any inflammatory secretion from the vein." Andral|| promulgated this doctrine, and Carswell^f likewise; alleging that with all the facts before us—namely, the existence of suppurative inflammation, the presence of a greater or less quantity of pus in the veins, evidence that the pus so situated is the product of inflammation of these veins, and of this morbid product being carried into the blood by the collateral venous circulation—it appears that a satisfactory explana- tion may be given of the formation of those anomalous collections of pus which take place in remote parts of the body. Dupuytren, Berard, Vidal** (de Cassis), and Sedillotjj concur in the doctrine of pus-trans- mission ; the latter observer maintaining that pus can actually be seen in the blood when examined under the microscope. Remembering the great difficulty of clearly distinguishing pus-cells from the pale corpuscles of blood, I cannot accord much weight to this argument. Certain observers have been content to record the important fact that suppurative phlebitis very frequently induces the constitutional disorder known as " pyaemia," without specifying its immediate cause. Ribes+jt. does not assign the transmission of pus nor any other explanation of this question ; neither does Breschet§§ nor Guthrie.|| || On the other hand, respecting suppurative phlebitis as a source of pyaemia; it is alleged by some observers, that the living membrane of veins is indisposed to inflame and is perhaps 'incapable of secreting pus. The systemic infection is attributed by Virchow, and other pathologists, to the disintegration and decomposition of fibrin, in the shape of coagu- lum within the veins, and Avhich enters the circulation. * Anat. Pathol, liv. xi. pi. 1. T Arch, de Me"d., 1828-29 : De la Phtebite Uterine, et de la Phlebite en general. X Journ. Hebdom. de Med., 1829, tome ii. : Sur quelques Accidens, &c, a la suite des Amputations. § Path. Inq. into the Secondary Effects of Inflammation of the Veins, 1829. || Pathological Anatomy. Trans. 1831, vol. ii. pp. 419 and 422. •; Elementary Forms of Disease, 1838, art. Pus and Purulent Deposits. ** Traite" de Pathologie Externe, et de M^decine Operatoire, 1846, tome deuxieme pp. 82-87. tt De l'lnfection Purulente, ou Pye"mie, 1849. XX Expose" sommairede quelques Recher. Anatom., Physiol., et Path : Me"m. de la Soc. Med. d'Ernulation, 1817, tome viii. p. 624. §§ De 1'Inflammation des Veines, ou de la Phle'bite : Journ. Complementaire du Diet, des Sciences Med., 1819, tome ii. p. 325, tome iii. p. 317. Illl Treatise on Gunshot Wounds, 3rd edit., 1827, p. 299. PYAEMIA, OR PURULENT INFECTION. 213 Others have denied the possibility of pus entering the circulation under the ordinary circumstances of suppurative phlebitis. Tessier* alleges that at all stages of venous inflammation the pus is enclosed in the cavity of the vein by clots or -false membranes, and that at no period of the anatomico-pathological existence of phlebitis, is its entrance into the blood possible. Mr. Lee appeals to the results of experiments on blood out of the body. In the preface to his Jacksonian Prize Essay,j he urges that " the simple experiment of mixing some pus with healthy, recently drawn blood, will at once show that such a combination cannot circulate in the living body. It will be found that the blood coagulates round the globules of pus, and forms a solid mass which will adhere to the first surface with which it comes in contact; and it will be evident that it is not till the coagulum thus formed is broken up or dissolved that its elements can circulate with the blood." But, Mr. Lee's inference from his " simple experiment " assumes that that which is true of blood mixed with pus out of the body, is also true of blood circulating with pus in the living body. The inference drawn breaks down, because the circum- stances of the two cases are so essentially different. This, as Hunter said, is " putting living and dead animal matter upon the same footing, which is a contradiction in itself." The inference which Mr. Lee has drawn from his experiments is therefore without appropriate foundation. (2) Suppurative Lymphatitis.—The fair inference from all the facts— pathological and clinical—which I have adduced is, that pus enters the general circulation during the course of suppurative phlebitis. By analogy, pyaemia may be expected to arise also from suppurative inflam- mation of the lymphatics. Similar symptoms to those of pyaemia arise occasionally after slight pricks and wounds received in dissection, and similar consequences ensue. How far this constitutional disorder, and these consequences, are due to the animal or septic matter inoculated, is uncertain. The very worst constitutional symptoms may follow the slightest prick where the quantity of animal matter introduced must have been minute; and equally bad symptoms may follow a bleeding wound where the animal matter has been washed away : while the most fatal cases are generally those of wounds received in the post-mortem exami- nation of uterine phlebitis with suppuration, and pus-forming peritonitis; and lastly, the constitutional symptoms are in the ratio of the local inflam- mation and suppuration. For these reasons I am inclined to regard the constitutional disorder arising from dissection wounds, when accompanied Avith inflammation of the lymphatics, as pyaemia, from pus having thus entered the general circulation. And as I have said, the symptoms and the consequences are similar. Severe rigors announce the transmission of pus; this primary symptom occurring, not at the time of the prick or cut, but after the lymphatics have become inflamed. Prostration, extreme, with a counte- nance expressing dread apprehension, show that the poison continues in operation. Partial reaction may succeed, but eventually the pulse becomes very weak and very rapid. A dusky yellow tinge sometimes overshadows the skin, and the tongue is coated with a brown fur. Foetid perspiration and alvine evacuations may apparently eliminate the poison and restore health, or oppressive wandering delirium betoken approaching * Archives Ge'ne'rales de Me"decine, 1839, iii. ; et nouvelle ser., t. i'v. p. 83. t On the Origin of Inflammation of the Veins, and on the Causes, Consequences, and Treatment of Purulent Deposits, 1850. 214 GENERAL PATHOLOGY AND SURGERY. death. Such are the chief general symptoms. Local and significant ones have also been noticed, and accurately described, by Macartney,* Colles, and others. As the disease progresses, inflammatory tumours arise suc- cessively in parts of the body remote from the original wound, and of a character which augments the constitutional sympathy, for they are not bounded by the effusion of lymph. According to Macartney, pus is rarely formed, and when these tumours have been cut into on the sup- position of their being abscesses, they have been usually found to contain only a bloody serum. Mr. S. Cooper statesf that, in a large proportion of the cases which he attended, purulent matter was formed and dis- charged. A common situation for such abscess is under the great pectoral muscle. Local signs of inflammation are frequently present. Colles} dwells on the significance of a peach-blossom redness, unlike the hue of erysipelas, and acute pain is sometimes felt in the part. Thus these secondary purulent collections, contrast somewhat with those which pro- ceed from suppurative phlebitis. (3) Arteritis rarely advances to suppuration, and more rarely are there any constitutional symptoms of pyaemia. But now and then, utter pros- tration, with an incredibly rapid pulse, suggest this inference, and the oppressive delirium of pyaemia speedily closes the scene. Post-mortem examination is wanting to complete our knowledge of these cases. (4) Suppurative phlebitis, suppurative inflammation of the lymphatics, and possibly, suppurative arteritis, are not the only sources of pyaemia; the immediate cause being the direct transmission of pus from the vessels in which it is formed into the general circulation. Precisely the same constitutional disorder frequently follows the absorption of pus from suppurating surfaces, as wounds and sores. Velpeau, Marechal, Rochoux, and others have attributed pyaemia solely to absorption, and in such cases. What are the particular circumstances which allow the absorption of pus from a suppurating surface, so as to induce pyaemia ? It is well known that pus may be absorbed from an abscess without pyaemia ensuing; and long since Cruveilhier§ pointed out the important dis- tinction between the absorption of pus when prepared for absorption, and pus in the condition of pus, at once entering the circulation. In the former case, no constitutional disturbance follows; in the latter, pyaemia. To allow of the absorption of pus in an unaltered condition, the absorbing vessels must have been laid open ■ the veins, lymphatics, or both, must have undergone solution of continuity; and this, either by a wound without subsequent repair, or by rapid sloughing, without time for closure of the vessels by the adhesive process. They therefore remain open during suppuration, and their mouths—so to speak—being in immediate contact with pus, allow of its admission, and transmission. This mode of purulent infection accords with Mr. Liston's observa- tion,! that, "when from any cause the extremity of a large vein in a wound is not closed—when it is not plugged up by plastic matter, pus seems to enter it readily, and by mixing with the circulating fluid, causes dreadful mischief. Great constitutional disturbance accompanies the purulent deposits which follow in the solid viscera and in the joints." In * On Inflammation, 1838, p. 105. t First Lines of the Theory and Practice of Surgery, 7th edit., 1840, p, 188. X Dublin Hosp. Reports, vols. iii. and iv. § Anat. Path. Inflam. des Sinus de la Dure" Mere, livraison vii., and Phl^bite UteVine, liv. iv. || Elements of Surgery, 1840, p. 154. PYAEMIA, OR PURULENT INFECTION. 215 other cases these results are preceded by rapid sloughing. A wound suddenly loses all power of healing by adhesion, and any adhesions that may have formed give way, the granulations become pale and flabby, and true pus is no longer discharged; the surface acquires a mottled brown colour, and by this time symptoms of pyaemia have commenced. Burns, attended with extensive suppuration, are not unfrequently followed by pyaemia; and certain specific diseases, as glanders, in like manner, threaten purulent affection by absorption. Occasionally, suppurative phlebitis advances so far as to allow of absorption through a vein having burst, and opened into an abscess. In one case, the femoral, popliteal, posterior tibial, and peroneal veins, communicated with abscesses (Cru- veilhier). In another case, the internal jugular vein opened into a neighbouring abscess (Travers). More frequently, inflammation of the lymphatics is accompanied with extensively diffused suppuration, and induces pyaemia, partly by the absorption of pus. Formation of Secondary Abscesses.—The mode of production of secondary abscesses, in various and remote organs and parts of the body, in consequence of purulent infection of the blood, is doubtful. It may be, by the arrest, and actual deposition of pus in the capillaries of the parts affected, conveyed there through the circulation—the theory originally entertained ; or, that the arrest of pus, or of disintegrated fibrin, in these vessels, induces suppurative inflammation—phlebitis, of the smaller veins. This latter mode of formation was suggested by Cruveilhier, and seems to be the more probable explanation of secondary abscesses. Exciting Causes, and their Operation.—Injuries'said surgical opera- tions attended with much suppuration, are well known to threaten pyaemia; and they do so partly, perhaps, by absorption of pus, and partly, by suppurative inflammation of the disorganized veins. Com- pound fractures may thus occasion purulent infection ; and injuries of the head probably operate chiefly by suppurative inflammation of the veins of the diploe. Dance first suggested this explanation ; Cruveilhier gave the anatomical proof by dissection. Indeed, the latter observer affirms that phlebitis of bones is one of the most frequent causes of visceral abscesses, from wounds and surgical operations implicating the bones. The mere removal of a piece of necrosed bone is sometimes folloAved by pyaemia; but whenever destruction of the osseous texture, accompanied with suppuration, is followed by pyaemia, absorption of pus probably has been partly the cause, its absorption being determined by the anatomical condition of the veins, which are kept open by the bony channels through Avhich they pass. Amputations of the limbs, of the breast, lithotomy, and the operation for fistula in ano, likewise threaten pyaemia, Avhen suppuration is abundant. Absorption and suppurative phlebitis may co-operate in these cases to infect the blood with pus. They assuredly co-operate in pyaemia following venesection. The vein is punctured, and the aperture absorbs pus, subsequently diffused around the vein; while the vein itself, having suppurated, transmits pus into the "•eneral circulation. Probably, suppurative inflammation of the lympha- tics contributes to pyaemia, in some cases where and when absorption of pus may have taken place. A faint blush in the course of the lymphatics frequently supervenes on the sudden cessation of a purulent discharge; forthwith pyiemic symptoms commence; eventually the lymphatic vessels appear as red lines ramifying from the sore, becoming harder and more painful—more inflamed, in fact, as pyaemia advances. 216 GENERAL PATHOLOGY AND SURGERY. Treatment.—Preventive measures will consist in the rigorous obser- vance of hygienic precautions, especially with regard to cleanliness in dressing a wound, and free ventilation; and in the preparation of the Patient for any operation (p. 11). Pyaemia is scarcely amenable to any remedial measures. Stimulants and tonics, with as much nutritious and readily assimilated food, as can be taken, constitute the only plan of treatment for probably sustaining the patient through the dread ex- haustion which must be undergone, even when recovery ensues. Thus, wine, brandy, or as brandy and egg-mixture, strong beef tea, ammonia and quinine—in large doses, as four or five grains, may be administered repeatedly, every three or four hours. Opium has a marked beneficial influence in controlling the rapidity of the pulse, and the general irrita- bility associated with prostration. Cleanliness in the dressing of any wound, and free ventilation, must also be observed. Secondary abscesses, when tense, and in any superficial or accessible part, may be opened; and by a valvular incision, as in the treatment of a chronic abscess, so as not to admit air to the readily decomposing purulent collection. CHAPTER X. hospital gangrene. Hospital gangrene is fortunately known to but few surgeons in civil practice now living; and we must refer to those of the past for informa- tion. The shortcomings of personal observation, are however amply compensated by the testimony of many witnesses on record; for a disease so formidable has ever been watched with deep interest whenever it occurred. From original sources of information, therefore, we are enabled to identify this disease, while its etiology suggests appropriate preventive measures. Hospital gangrene has received various other names ; not because of any doubt respecting its pathological nature, but as expressive of its various characters, and mode of origin. Thus, Pulpy Gangrene, Phagedaenic Gangrene, Sloughing Phagedaena, Putrid Ulcer, Pourriture, Contagious Gangrene, and Hospital Sore, are severally synonymous. Signs, and Diagnostic Characters.—Overlooking the many phases of this gangrene, and regarding only its more constant phenomena, its nature is perhaps best expressed by denominating it, essentially,— gangrenous inflammation; that is to say, inflammation certainly, but inflammation passing at once into gangrene, thereby appearing only a process of textural disintegration and disorganization. Sometimes the process of destruction resembles more that of phagedaena, alternating with rapid sloughing; so that the worm-eaten phagedaenic surface sud- denly becomes a large slough, and then again phagedaenic. These different aspects of the disease are apt to mask its really gangrenous character. What, then, are the phenomena more constantly observed? Acute pain, sudden engorgement and bloated swelling, dusky-red dis- coloration around the doomed part, and conversion of its textures into a putrid glutinous or slimy slough, exhaling a peculiar foetid odour. Rapidly extending, all the soft textures are soon melted down, leaving HOSPITAL GANGRENE. 217 only the bones staring, of an ebony black,—as if the rafters of a house where a fire has raged. These general characters are clearly visible in the portraits of this disease, drawn by eye-witnesses; varied, however, by special circum- stances ; principally, by the previous kind of injury to the part affected, the textures engaged, and the constitution of the individual. Origin and Course.—To identify this gangrene under the modifying circumstances referred to, it is necessary to trace its origin and progress —in a stump after recent amputation, as an incised wound, or granu- lating a3 an ulcer, a recent gunshot wound, a small puncture, an old sore, and lastly, a blistered surface. For the particulars of these six aspects of Hospital Gangrene, I avail myself, chiefly, of Blackadder's original and valuable treatise. (1) When a stump is affected, and the patient has a plethoric habit, or is accustomed to live freely, intense inflammatory action soon runs through its whole substance; swelling rapidly increases, so that in a few days the stump acquires more than twice its former size, and being much indurated, occasions the most excruciating pain. In this state the patient may become delirious, and die suddenly by effusion into some of the larger cavities. More frequently, however, gangrene seizes upon the integuments and cellular texture, large sloughs are thrown off, and some of the larger blood-vessels giving way, the patient sinks under the exhaustion of repeated haemorrhage. For it is commonly found that the usual modes of stopping haemorrhage from a stump are in such cases either inadmissible or totally inefficacious. Sometimes the progress of the disease in a stump is more gradual, yet ultimately nearly as fatal— inflammation is much less acute—there is comparatively little tumefac- tion, and the pain is far less severe; but the discharge is much more copious, and the cellular texture connecting the integuments and muscles is rapidly destroyed. Haemorrhage generally supervenes later than in the preceding instance ; it is, however, the most common cause of death. Sometimes, a stump, almost soundly cicatrized to all appearance, will suddenly burst open and undergo gangrenous disintegration. Such cases are well described by John Bell.* In one day he saw three stumps burst open, each of which had so nearly cicatrized, that you could have covered the small spot remaining unhealed with the tip of the little finger. When this gangrene supervenes after any amputation, the case may be regarded as that of an incised wound, healing probably by adhesion, but suddenly diverted from primary union, and undergoing the aforesaid process of destruction. (2) Observe the same gangrenous inflammation supervening on a healthy granulating wound, or ulcer. + The ulcer becomes painful and SAVollen, loses its healthy florid appearance, while the granulations, which Avere small and distinct, become flabby, and in some cases appear as if they were distended Avith air; in others, vesicles containing a watery fluid or bloody serum, have been observed, and the sensation in the sore has been described as resembling the stinging of a gnat. The secretion of pus is arrested, and the surface is covered with a tenacious viscid ash-coloured matter, which adheres firmly. After some time a discharge * Principles of Surgery, ed. Charles Bell, 1826, vol. i. p. 144. + Observations on Hospital Gangrene, with reference chiefly to the Disease as it :l,,peared in the British Army during the late War in the Peninsula. John Boggie, M.D., 1818, p. 42. 218 GENERAL PATHOLOGY AND SURGERY. of thin ichorous matter ensues, a very peculiar cadaverous febrile smell, the pain increases, the edges of the sore are reverted, and generally assume a circular form ; an erysipelatous redness encircles it, extending possibly to a great distance, even over a whole limb; the neighbouring glands, as those of the axilla or groin, swell, inflame, and perhaps suppurate. Omitting the constitutional symptoms thence arising, the local inflammation goes on apace, thin ichor continues to be discharged in great quantity, and a thick slough, apparently of coagulable lymph, like melted tallow, covers the whole surface of the sore, the fcetor is intolerable and the pain insupportable. At last an oozing haemorrhage soaks the dressings, or a larger blood-vessel having sloughed, robs the patient of his last remaining source of strength, and the typhoid con- stitutional commotion soon terminates in death. Blackadder noticed that when the disease attacks a large recent wound, its whole surface may be affected at once; while in other cases, the gangrene commences on, or near, the lips of the sore. (3) Passing from incised to contused wounds, " when," says this authority, " the disease attacks a recent gun-shot wound, the discharge, two or three days after contagion, is found to be lessened, and to have become more sanious than purulent. The sore has a certain dry and rigid appearance, its edges are more defined, somewhat elevated and sharpened, and the patient experiences in it a stinging sensation, as if occasioned by a gnat. Then, or a day or two later, the integuments at the edge of the sore become inflamed, and the surface of the sore itself assumes a livid or purple colour, and appears covered with a fine pellicle, such as forms on coagulating blood." (4) " When," observes Blackadder, respecting hospital gangrene attacking a puncture or scratch, "the morbific matter is thus inserted, its first appearance resembles that of a part inoculated with vaccine virus." The primary inflammation begins at the end of the second, or early on the third day ; it reaches its height about the sixth ; but when the scab begins to form in one disease, phagedanic ulceration begins in the other, and if allowed to proceed soon affords sufficient proof of the non-identity of these diseases. (5) Should the disease attack an old sore, where a considerable depth of new texture has been formed; a vesicle arises, filled with a livid or brownish-black fluid, which bursts and assumes the appearance of a small dark-coloured spot. Such vescicle, or spot, is usually situated at the edge of the sore. Phagedaenic ulceration, spreading therefrom, makes comparatively very slow progress through the surface-bed of new texture, but having reached the subjacent natural texture, its progress is suddenly accelerated, acute inflammation supervenes, and a large slough forms. (6) Lastly, when attacking the skin from which the cuticle has been removed, as by a blister, one or more, small vesicles first appear, filled with a watery fluid, or bloody serum of a livid or reddish-brown colour. The situation of this vesicle also is generally at the edge of the sore. Its size is not unfrequently that of a split garden-pea, and is easily ruptured, the pellicle which covers it being very thin. If the vesicle contain a wTatery fluid, and has not been ruptured, its appearance re- sembles a greyish-white slough ; if containing a dark-coloured fluid, or if ruptured, it appears a thin coagulum of blood, of a dirty brownish- black colour. During the formation of the vesicle a painful sensation in the sore is generally experienced, like that of a gnat stinging. HOSPITAL GANGRENE. 210 Thus the earliest and most elementary phase of Hospital Gangrene may be vesicular ; just as gangrene generally begins, and senile gangrene in particular. The features peculiar to, and characteristic of, this so-called Hospital Gangrene, ensue subsequently—its slimy slough, its rapid progress, its appalling deA-astation. I shall presently have to notice one character which foretells all the rest, I mean propagation by contagion, and possibly by infection also, whereby the disease runs through a whole Avard—a whole hospital if unchecked, passing from bed to bed with the rapid strides of death. The local results to be anticipated are always sad, sometimes shocking. Among Blackadder's cases; in one, half of the cranium was denuded, the bones Avere black as charcoal, the integuments detached posteriorly to the second cervical vertebra; anteriorly, to the middle of the zygo- matic process of the temporal bone; and this was originally only a superficial scalp wround. In another case, the integuments and cellular texture, on the anterior parts of the neck, were destroyed, and the trachea laid open, presenting a horrid spectacle. Among John Bell's cases, in one, the skin and muscles Avere carried away from the shoulder down to the bellies of the supinator muscles; and eventually, when the sloughing terminated, nothing seemed to be left of the arm except the bone, covered with a velvet-like surface of shining red flesh; and this Avas originally only a narrow splinter wound on the middle of the outer side of the arm. Continuing our course doAvn the body; in one case, a very slight and superficial Avound of the thigh grew into a sore, at first no bigger than the palm of one's hand ; in tAvo days as large as the crown of a hat; and in a week the whole skin of the thigh Avas destroyed, the muscles Avere stripped of skin and fascia from the hip to the knee, the trochanter was almost laid bare, the hamstring muscles were exposed to a considerable extent, and all the muscles of the thigh dissected in a manner which no drawing could express. With even these cases in view, imagination will scarcely realize the ravages of this gangrene. A tattered skeleton, still held together by ligaments ? No; for the joints may be laid open extensively, and the knee, ankle, elbow, or wrist disarticulated. Constitutional Disorder.—Long before any such irreparable injury has been inflicted, the constitutional powers take affront. The period, hoAvever, at which the constitution begins to exhibit symptoms of irrita- tion is extremely irregular, sometimes as early as the third or fourth day, sometimes as late as the twentieth. The countenance assumes an anxious or feverish aspect; the appetite is impaired ; thirst succeeds, and the tongue is covered with a white mucus. Some constipation at first, ends in diarrhoea. The pulse is rather irritated than accelerated. The general symptoms, however, have an inflammatory or typhoid character, accord- ing as the causes of either predominate. When an inflammatory dia- thesis prevails, the system becomes gradually more irritated, until acute inflammation attacks the sore, an event that frequently happens about the end of the second Aveek. At this period the pulse is frequent and sharp, and not uncommonly the patient undergoes one or more shivering tits, succeeded by great increase of heat, seldom or never terminating in a profuse perspiration. The cold fit is sometimes followed by a bilious intestinal evacuation, with mitigation of the febrile disorder. If the local rhischief be not arrested, weakness increases daily to exhaustion; the fever loses its inflammatory character, and unless the patient be cut off by haemorrhage, he falls a victim to extreme debility. When the 220 GENERAL PATHOLOGY AND SURGERY. disease has a typhoid character, the pulse is small and frequent, the appetite and strength gradually fail, not unfrequently diarrhoea super- venes, and the patient at length sinks, retaining his mental faculties to the last. Causative Relation of the Local and Constitutional Conditions.— Whether does the constitutional disorder or the local disorganization precede ? What is the order of succession ; which is the cause ; which the effect ? Authorities are nearly equally divided on this question; but the weight of authority decidedly preponderates in favour of the local origin of hospital gangrene. (1) Local Origin.—Blackadder affirms—" that in no single instance which I had an opportunity of observing, did the constitutional symp- toms precede the local; unless the case be held an exception, where a stump became affected after amputation had been performed, on account of the previous effects of the disease.—That the morbid action could almost always be detected in the wound or sore previously to the occur- rence of any constitutional affection.—That in several instances the constitution was not affected until some considerable time after the disease had manifested itself in the sore.—That when the disease was situated on the lower extremities, the lymphatic vessels and glands in the groin were observed to be in a state of irritation, giving pain on pressure, and were sometimes enlarged before the constitution showed evident marks of derangement.—That the constitutional affection, though some- times irregular, was in many cases contemporary Avith the second, or inflammatory stage.—That when a patient had more than one wound or sore, it frequently happened that the disease was confined to one of the sores, while the other remained perfectly healthy, and this even when they were at no great distance from each other." To these five arguments three more may be gathered from Welbank's well-known essay,* forming so much additional support in favour of the local origin of this disease.—Thus the fact of its earlier stages being attended with little or no constitutional disturbance, was also noticed and urged by Welbank ; and, "that when such disturbance does super- vene, from the increased extent of the local malady, and unites in alliance doubly subversive of healthy processes of resistance, the latter stages of the disease are progressively accelerated.—That part of the diseased surface may clear off and granulate, while gangrenous disorganization continues progressive at the opposite edge.—That, however advanced the sore, it not unfrequently becomes healthy, and rapidly so, on the appli- cation of appropriate local measures;" and, " that the symptoms of general disturbance also which supervene are promptly relieved by measures that control the local condition." Partly at variance with these facts and arguments, is the experience of Guthrie,j " That the febrile symptoms do seem to follow the appear- ance of the local alteration, is, in many cases, indisputable ; that they precede or accompany the local symptoms in many other cases, is in- disputable; and that the disease in a mild state, although capable of committing much mischief, is neither preceded nor followed by febrile or constitutional symptoms, cannot be doubted." (2) Constitutional Origin.—On the other hand, there are, or have been those who affirm that the constitutional disorder generally, at least, pre- * Med.-Chir. Trans., vol. xi., 1820. t Commentaries on the Surgery of the War in Portugal, &c, 1855, p. 165. HOSPITAL GANGRENE. 221 cedes the local disorganization. Thus, John Bell wrote :*—The hospital sore is usually preceded by a degree of fever. Thomson—writing also from his own observations—states,y that these two classes of symptoms— the local and constitutional—are not invariable in the order of their ap- pearance ; for sometimes the one, and sometimes the other class, seems to occur first in the order of succession ; but that the constitutional symp- toms usually precede the local. Hennen also advocated this doctrine even more strenuously. The question of local or constitutional origin may be further examined by reference to the knoAvn causes of hospital gangrene. External Causes.—All observations respecting the etiology of this disease agree in certain particulars ; that it is not developed epidemically, but rather as an endemic, springing up in some way among those who become affected. Thus, newly-built hospitals are free, so also are gene- rally those built on high ground; Avhile the disease arises in crowded and ill-ventilated hospitals. Infection.—Thomson regards the disease as possibly infectious. " I have seen (says he) hospital gangrene introduced into an hospital by a single individual, and, when proper precautions were not taken, spread extensively among the other patients, but chiefly among those who lay nearest in the Avard to the person originally affected or among those who had had most frequent intercourse with him. I have also knoAvn patients attacked in succession with hospital gangrene who had used the same bed- ding, or Avho, without using the same bedding, had occupied in quick suc- cession the same small apartment." Fomites, therefore, can convey the infectious matter, and retain it some time. So highly infectious is this disease, according to Boyer's observation,| that it broke out in wounded patients, who, hoping to escape, had quitted the infected hospital, and retired to elevated situations Avhere they breathed the most salubrious air. The infecting distance, or range of the contaminated air from the focus of infection, is unknown; but the disease certainly attacks patients at some distance apart (Thomson). Nor is the period of latency, after in- fection, more exactly determined. " I think (says this author), I have repeatedly seen the disease attack patients in less than three days after they had been exposed to its influence." The production of hospital gangrene by infection seems to be dis- proved by Blackadder's observations, and chiefly by the result of the fol- loAving experiment. He placed three patients with clean wounds alter- nately between three other patients severely affected. Their beds Avere on the floor, and not more than tAvo feet distant from each other; but all direct intercourse was forbidden, and they were made fully aware of the consequences of inattention to their instructions. The result was, that not one of the clean wounds assumed the morbid action peculiar to the disease, nor Was the curative process in any degree impeded. Contagion.—This mode of communication can be traced as the only cause in all cases since the days of La Motte, 1722, and Pouteau, in whose posthumous works, published 1783, hospital gangrene Avas first specially noticed. Pouteau observed that it may be communicated to the most healthy wound or ulcer in a person of the best constitution, and breathing the purest air, by merely placing in contact with any such » Principles of Surgery, ed. cit., vol. i. pp. 142, 147. t Inflammation, p. 458. + Traite des Mai. Chir., torn. i. p. 322. 222 GENERAL PATHOLOOY AND SURGERY. wound or ulcer, sponges, lint, &c, contaminated by contact Avith a sore un- dergoing the disease. Thomson concurs in the accuracy of this observation as well as advocating the infectious character of hospital gangrene. Delpech* traced its propagation in almost every instance to the direct applica- tion of the morbific matter to the sores. Blackadder also recognised this mode of propagation in ninety-nine cases out of every hundred. Welbank arrived at a precisely similar conclusion. He speaks of the disease as being highly contagious by using the same sponges to different patients.-)- And Guthrie specifies this as one of the " conclusions "J of his observations during the Peninsular War. Nay more, that it is conta- gious through the medium of the atmosphere applied to the wound or ulcer. Boggie's experience§ during the same war compelled him to admit that hospital gangrene may be propagated by contagion, although he is dis- posed to attribute less importance thereto than to the continued operation of other local causes of an irritating character, in the shape of dirt, acrid applications, motion or mechanical irritation, attributing also consider- able importance to other stimulating causes affecting the constitution ; as hot weather, stimulating food, and the intemperate use of wine and spirituous liquors. In short, Boggie considers it inflammatory gangrene, and recommends antiphlogistic regimen. While, however, admitting that all such causes may predispose to hos- pital gangrene, it does not arise in numberless instances where these and similar causes are conjoined in full operation. Their essential impor- tance, therefore, cannot be allowed. The etiology of hospital gangrene is so far obscure that its cause or causes, in the first instance of its occurrence, require further elucida- tion. The general conclusion is this:—The disease may possibly arise from over-crowding in an ill-ventilated hospital or other institution ; and is perhaps communicated by infection, from the sore itself emitting a poi- sonous exhalation; but it is assuredly also propagated by contagion. Treatment.—Guided by the etiology of hospital gangrene, the nature of our preventive measures is at once suggested. When the first case appears in any hospital or other institution, our immediate object is to decompose the poisonous slough and discharge, and, moreover, arrest the progress of gangrene. Strong caustics such as will fulfil these inten- tions, should therefore be forthAvith applied. Arsenic was originally recommended by Blackadder. The liquor arsenicalis, or diluted with an equal quantity of water, or with twice that quantity, was used, according to the emergency of the case. Strong nitric acid was first employed by Welbank. Either of these caustics, or even the actual cautery, should be applied until a new, hard, dry slough is formed, encrusting a clean and healthy surface. To prevent the propagation of this gangrene, punctilious cleanliness as regards the hands of the dresser, lint, water, and other appliances, should be daily observed in dressing all other wounds, even the most trivial and healthy. The bedding, also, should be changed, and clean linen furnished, as often as may be necessary to pre- vent their impregnation and the accumulation of fomites. Free ventila- tion and isolation of the patient will have similar preventive efficacy, and * Me"m. sur la Complication des Plaies et des Ulceres comme sous le nom de Pourriture d'Hopital, 1815. f Op. cit. X Commentaries on the Surgery of the War in Portugal, &c, 1855, p. 171. § Op. cit. HYDROPHOBIA. 223 should not be neglected, although the disease may not be assuredly infec- tious. Constitutional treatment must have reference to the combined state of irritation and debility; by the administration of opium, quinine, and stimulants. The protective value of these measures has long since been fully es- tablished by their results. Thus, in military hospitals, the disease is apt to occur. Y/et my own experience in respect of hospital gangrene, as it appeared during the late war, in the hospitals in the Crimea and at Scutari, does not approach Avhat was formerly daily observed in civil hos- pitals. In the Hotel Dieu, for example, it raged without intermission for two hundred years—so much so that " a young surgeon," says an ancient French author, " who is bred in the Hotel Dieu, may learn the ■ various forms of incision, operations too, and the manner of dressing wounds; but the way of curing them he cannot learn. Every patient he takes in hand must die of gangrene." Now-a-days, such scenes have passed away like a dream. This disease has not been witnessed for many years in the hospitals of this country, excepting on two occasions,—in the Middlesex Hospital, 1835,* and in the University College Hospital, 1841. j With these exceptions, true hospital gangrene—contagious gan- grene—has not reappeared; and many experienced surgeons of the present day have no practical knowledge of it whatever. The disappearance of a disease, once so frequent, once so formidable, can only be attributed to its causes having since subsided ; and they are precisely the circumstances that have been specially obviated by the hygienic arrangements of the well-appointed and well-regulated hospitals of recent years; never- theless, we are still bound to recognise hospital gangrene and to remem- ber its etiology, as the best security for our continued observance of those protective measures which can alone prevent the recurrence of this disease in future. CHAPTER XI. poisoned avounds. Hydrophobia. Hydrophobia is the constitutional disorder in the human species which arises from contagion with the saliAra of a rabid animal. Formerly, the reality of a hydrophobic virus was doubted, and even noAv-a-days the importance of a well-grounded belief on this starting- point must be obvious in relation to the appropriate means for preventing the consequences of the bite of a rabid animal. The dog and cat, and other animals of the canine and feline species, are peculiarly prone to hydrophobia; and there is abundant evidence to show that the bite of a " mad do"-, cat, wolf," &c, induces this disease by virtue of the saliva thus introduced. The wound itself is often trivial—a mere scratch or graze from a tooth of the animal in the act of snapping; yet a very large proportion of * System of Surgery, Chelius, trans, by South. f Lancet, 1845, vol. i., Lectures, Lisbon. 224 GENERAL PATHOLOGY AND SURGERY. persons bitten by a rabid animal undergo hydrophobia, sooner or later, and die ; and it is incredible to imagine that so many individuals, differ- ing in their constitutional idiosyncrasies, should alike experience the same constitutional disorder, and that a fatal one, from a wound scarcely worthy of the name. The (morbid) saliva introduced by a scratch, itself trivial, is the only peculiarity of such lesion, and a very significant one. Many recorded facts, read in this light, become intelligible. Of fifteen indi- viduals bitten by a mad dog, and attended at Senlis, by the Commissioners of the French Royal Society of Physic, ten were bitten on the naked flesh, and five through their clothes. Of the former, five proved fatal. Near Rochelle, twenty-four persons were bitten by a rabid wolf, and eighteen of them perished.* The existence of a hydrophobic virus, in the shape of a peculiar morbid saliva, has been also demonstrated experimentally. Several animals were inoculated with the saliva of a rabid dog, recently dead ; a dog, a cat, a horse, and a cock were thus infected by Dr. Zine. Dupuy, in like manner, induced the disease by taking a sponge, which had been bitten by a mad dog, and rubbing it on the open sore of a sheep. Youatt drew a silk thread backwards and forwards through the mouth of a rabid animal, and having inserted it as a seton in the neck of a sound dog, this animal subsequently died of hydrophobia. If, then, the inoculation of a peculiar virus be indisputably the cause of hydrophobia, is this disease capable of being conveyed by clothes im- pregnated therewith ? Can it be communicated by fomites ? Clearly so ; for a dog's tooth is itself a fomes. To this effect, also, Mr. Trevelyan, writing to Dr. Bardsley, states that, after losing one pack of hounds by rabies, he not only removed the straw, but had the benches of the kennel scalded with boiling water, and afterwards all the joints painted and filled up with hot tar; the walls were then whitewashed, and the pavement cleaned with hot water. Thus secure as he imagined, he collected another pack ; yet rabies again broke out and recurred year after year. In consequence of these continual attacks, he removed the pavement, threw the earth beneath into the river, refitted, new painted, and white- washed the kennels; ever after which the pack continued perfectly healthy. The saliva of a rabid animal being the source of hydrophobia by con- tagion, explains many things otherwise anomalous. This virus is usually introduced through a bite of the animal diseased, but the mere applica- tion thereof to ever so slight a wound, scratch, or other solution of con- tinuity, in an absorbing surface, is sufficient. In such case, the lick of a rabid dog generally induces hydrophobia. The surety of inoculation will obviously be affected—by the number of wounds inflicted, by lodge- ment of the virus or its escape by haemorrhage ; and above all, by unob- structed inoculation through the naked flesh as compared with the protection offered by clothes. Apart from these modifying circum- stances, in some cases no evil consequences ensue from the bite of a rabid animal, and the. immunity enjoyed must be ascribed to some unknown peculiarity of constitution. Local Condition.—Overlooking exceptional cases, hydrophobia ensues in a variable period from the date of the reception of the virus. The wound has generally healed, or it may not have healed quite soundly. * Recherches sur la Rage, Audry, ed. 3, p. 196. HYDROPHOBIA. 225 In either case, slight pain of a rheumatic character shoots from the site of the bitten part to some distance; so that if the hand be the part first affected, the pain extends up the arm and shoulder, fixing itself in the trapezius muscle probably, or the proximate side of the neck. Some- times a tingling heat, or even a sensation of cold, is experienced, rather than pain ; but either sensation equally extends,—say, up the arm and shoulder. Generally, actual pain is felt, and eventually snooting towards the heart. Meanwhile the cicatrix swells, reopens, and discharges an ichorous matter. Occasionally no local symptoms occur; neither the customary radiating pain, nor any inflammatory condition of the cicatrix. Constitutional Disorder.—After the lapse of some days perhaps, other and more formidable, because constitutional, disorder begins. The nervous system, together with its ally, the muscular, are the subject of all those phenomena which characterize this affection. The cerebro-spinal axis acquires undue susceptibility. Rapid-flowing thoughts, reviving memory, and fertile imagination, are expressed by a more animated manner and conversation; although, in some cases, a downcast pensive mien, yet Avithal irritable and peevish manner, prevails. Far more frequently, hoAvever, thoughts and fancies whirl through the brain tumultuously. A dull heavy pain caps the head and oppresses the temples, light is into- lerable, and the slightest noise jars the whole frame; while sleepless nights or starting dreams, an overwhelming dread, muscular twitches, and pains in the neck, back, and limbs, complete the picture of morbid excitement—bordering on delirium. This state of comparative ease lasts only four or six days, possibly only a day or two; when the most re- markable symptom of true hydrophobia supervenes,—an indescribable dread of fluids ; any attempt to drink—even the sight or sound of water, the thought of it, or anything associated therewith, as the noise of tea- cups, or of a pump—immediately excites a convulsive paroxysm, threaten- ing suffocation. In some cases the slightest breath of air, a fly settling on the face, or a bright light, has the same effect. These convulsive attacks are paroxysmal Avith complete intermissions. A viscid mucus accumulating in the mouth occasions an incessant action of the lower jaw to extricate it. The pains noAV piercing the epigastric and praecordial regions, more particularly, the general sensibility, becom- ing more and more acute, and the convulsive paroxysms more frequent, desperate and protracted, soon exhaust the patient's bodily power, while his mind is hurried on to furious mania; and thus, Avhen fighting for breath, or utterly worn out, the poor sufferer expires. The second or third day usually brings this happy release. It may be postponed to the fifth or sixth day. Age makes some difference, for children endure not longer than tAventy-four hours generally. Diagnosis.—I have italicised those symptoms which, contrasting with the phenomena of tetanus, serve to distinguish hydrophobia. To these characteristics may be added two more;—the early period of death from rabies as compared with tetanus, and its longer period of latency. On this point, hoAvever, considerable extremes are recorded. Period of Latency.—In one hundred and thirty-one cases, none of the patients became ill before the eleventh day after the bite, and only three before the eighteenth day. In tAvo hundred and twenty-tAvo cases, the disease sliOAved itself eleven times before the tenth day; tAventy-one, betAveen the tenth and tAventieth day; tAventy, from three to six weeks; eighty-nine, from seven Aveeks to seven months; eighty-nine, from seven Q 226 GENERAL PATHOLOGY AND SURGERY. months to twenty-seven months; one, after four years; one, after five and a half years. In Hamilton's table, it occurred in seventeen cases, between eighteen and thirty days; in sixty-three, between thirty and sixty days; in thirteen, between three and six months; in seventeen, between six and twelve months; in four, from ten to twenty months. In both these series the period of incubation extended to between the third and eighth week. The extreme periods, as determined by Dr. J. Hunter, were thirty-one days and eighteen months. The most extensive and authentic observations accord about forty days as the mean period of latency in the human subject. Here, then, is a season during which preventive measures can be employed with the prospect of success. Treatment.—Prompt removal of the hydrophobic virus by the cupping- glass, and free excision of the bitten part, constitute the most effectual preventative. In a part so situated that excision is impracticable, free cauterization may be resorted to, with strong nitric acid, potassa fusa, or nitrate of silver. It is impossible to say how late, in the period of incu- bation, these means would prove successful; for, if not employed in any given instance, some constitutional peculiarity might itself avert the super- vention of hydrophobia. There is just this poor chance of safety. But, considering the very large proportion of cases in which the disease does inevitably arise, no time should be lost. Excision, therefore, should be practised at the earliest opportunity, and not postponed, however long it may have been neglected; provided, of course, that in either case there be sufficient reason for believing or suspecting that the bite wss inflicted by a rabid animal. Before, then, resorting to a measure which entails permanent muti- lation, more or less; the state of the animaVs health in question should at once, if possible, be inquired into. The dog and cat chiefly concern us in this country. Rarely is the rabid state any approach to the popular notion of a " mad " dog. No wild excitement appears, no savage ten- dency to bite, and certainly no dread of water, so remarkable in the human subject. Rather will suspicion be aroused on ascertaining that the animal evinces only some strange departure from its usual habits and manner. In very many instances this peculiarity is a disposition to pick up straw, bits of paper, rag, thread, or any small object in the way. The animal laps water greedily. A disposition to lick is noticed in some cases, and particularly to lick anything cold—cold stones, or the cold nose of another dog; great aversion, however, to strange dogs and cats, especially to the latter, is very commonly observed at an early period. Some such unusual propensity is soon followed by an irritable, peevish manner. The animal snaps those about it, and resolutely fights if the least provoked, soon becoming furious. When thus obviously dangerous, it is forthwith secured. Yet a dog dangerously rabid may be perfectly quiet and natural, save in respect of some unsuspicious, because unobtrusive, symptom. Allowed to run about, patted and played with as usual, it bites in an unguarded moment. In this state, therefore, as well as when obviously rabid, the animal should be at once chained up. Instead of being killed, it can then be watched, to ascertain the real nature of its indisposition; thereby determining the necessity for excision in the case of any person who has been bitten. If the animal be affected with rabies, it will probably die in a few days; and this operation is imperatively demanded as the only means of preventing hydrophobia in any of the human species Avho, having been bitten, would otherAvise perish eventually. The safe HYDROPHOBIA. 227 custody of the rabid animal will also effectually prevent further mischief being done during his short period of probation. Supposing an animal, not itself rabid, or bordering on that condition, to have been bitten—a healthy dog, bitten by another dog, decidedly rabid. The latter will, of course, be killed; but when may the former apparently healthy dog be allowed to go free ? This question, bearing directly on the spread of rabies among animals, bears equally on the prevention of hydrophobia in the human species, by eradicating the source of this disease. The question turns on the period of latency among animals. In the dog it is considered to terminate about the end of the sixth week. At the Veterinary School, Alfort, when a dog is bitten, it is chained up for fifty days, and, if healthy at the end of that period, is restored to its master. Mr. Samuel Cooper used to mention in his lectures, at University College, an instance of a more extended period than that which regulates the pre- ventive measure adopted at Alfort. A large NeAvfoundland dog, having been bitten by another dog, did not become rabid until seventy days had elapsed ; information the more valuable, since Mr. Cooper himself Avatched the case from beginning to end. In Lord Fitzwilliam's pack the disease appeared at various intervals, from six weeks to six months.* We may therefore conclude, that an animal bitten by another in a rabid state should be chained up for a longer period than the experience at Alfort would suggest as an adequate preventive injunction—imprisonment for six weeks. Preliminary to this question is another—the communicability of hydro- phobia or rabies among animals and man,—a consideration essentially relating both to its propagation and prevention. Many facts tend to show that the communicability of this disease depends on the inherent capa- bility of the animal affected to engender it spontaneously; failing Avhich, he may bite in vain. The dog can generate rabies, and therefore can communicate it to another animal, or to man, in the shape of hydro- phobia. Sheep, horses—the herbivora—and man cannot generate the disease, and therefore cannot communicate it. Thus, rabies in a flock of sheep, consequent on the bite of a rabid dog, is not communicated from one sheep to another, although the sound are often bitten by the diseased, and in parts stripped of wool (Dupuy). At the Alfort Veterinary School three sound sheep, tAvo dogs, and a horse Avere inoculated Avith the saliva of a rabid horse; not one of them became affected. In keeping Avith this vieAV, man cannot communicate hydrophobia. By the experiments of Vaughan and Babington, animals Avere inoculated with the saliva of hydrophobic patients, but Avithout any effect. In an exceptional experi- ment by Magendie and Breschet, one dog of tAvo thus inoculated became affected ; but this animal might have been previously diseased, especially as rabies Avas rife at the time. Paroisse inoculated three dogs with the saliva of a man in hydrophobia; the animals Avere kept and Avatched for nearly four months afterwards, during all Avhich time they remained quite unaffected. Similar experiments were conducted by Gauthier, Giraud, Girard, and Bezard, with the same negative results. Lastly, there is no instance of one human being acquiring hydrophobia from another labouring under this disease, although in many instances atten- dants have been bitten by such persons. ■• Morbid Poisons, R Williams, M.D. a 2 228 GENERAL PATHOLOGY AND SURGERY. In conclusion, the general inference to be drawn from these facts is this—that in estimating the danger to human life incurred by the liberty of rabid animals, those only which can generate rabies—e.g., the dog— are dangerous. The human species affected with hydrophobia is harm- less, should there be any tendency to bite. Such considerations, coupled with a due knowledge of the duration of latency in different animals, particularly the dog, suggest adequate pre- cautionary restraint; while, in the event of hydrophobic virus having been communicated to man through the bite of a rabid animal, the pre- vention of the disease then impending is fulfilled by free excision of the part bitten, as soon as possible, aided, if necessary, by cupping. Curative treatment will be utterly useless, although it may be possible to palliate symptoms and prolong life. This may perhaps be effected by the plan of treatment recommended by Marshall Hall and Todd. It con- sists in removing all causes of irritation, bodily and mental, as by placing the patient in a darkened room, excluding any draught of cold air, all noise and conversation. The application of an ice-bag along the whole length of the spine seems to have some influence in allaying the excita- bility of the cord; while stimulants and nourishment support the patient in the exhaustion consequent on the convulsive paroxysms. Snake-bites.—Of Poisoned Wounds, in the ordinary sense, the bites of venomous snakes, happily of rare occurrence in this country, possess much surgical interest; chiefly with the view of preventing their constitu- tional effects, rather than the more hopeless intention of curing them. The local effect of a poisoned wound is essentially cellulitis ; inflammation of the subcutaneous cellular texture, announced by acute burning pain, accompanied with some, and perhaps, subsequently, enormous diffused swelling, not at first involving the skin. In severe cases the swelling spreads rapidly, and to an almost unlimited extent, so Avidely may it range. The bites of the rattlesnake and of the cobra di capello answer to this general description. Local condition.—A piercing pain is immediately felt, rapidly shooting through the limb ; swelling quickly succeeds, and a mottled livid redness, indicating that the skin is now involved. The cellular texture of the whole limb, and perhaps down the proximate side of the trunk, becomes gorged Avith a bloody sanious fluid; and, as if to relieve this tense yet diffused swelling, phlyctenae arise here and there. Very shortly the pain abates, the tension is exchanged for a flaccid softness, the limb is cold and benumbed; while patches of gangrenous skin announce that the work of destruction has commenced, not however disclosing the ravages already wrought beneath the skin in the subcellular texture, and still less the extent to which it may eventually be sacrificed. Constitutional Disorder.—Rapidly as all this mischief is accomplished, the constitutional disturbance begins almost concurrently with the first introduction of the poison. Soon after the poisonous bite has been in- flicted, symptoms of muddling intoxication ensue. The victim mumbles incoherently, and staggering, as if dead-drunk, is overcome with helpless prostration and oppressed breathing. Other and even peculiar symptoms are witnessed. Profuse cold SAveating, bilious vomiting, and perhaps evacuations of bile; while a yellow hue overcasts the skin. Excruciating pain about the navel is sometimes experienced. The pulse quivers irregularly, the nervous system succumbs to the potent poison, and the sufferer expires. HYDROPHOBIA. 229 Now, in order to prevent this fatal issue, and, moreover, the for- midable antecedent symptoms, remember the poison begins to operate almost immediately, varying in this respect, however, with the dose. Still its period of latency is short. Period of Latency.—In one case—carefully recorded by Sir E. Home*—a man was bitten by a rattlesnake at half-past two p.m., and brought to St. George's Hospital, by three o'clock; during this brief period of only half an hour the constitutional disturbance had become overwhelming; and in the interval, when the man went of his own accord to a chemist's shop for relief, he was observed to stagger, and appeared drunk. Death ensued. In another instance,y the bite of a rattlesnake began to manifest its effects within the first half hour. Treatment.—If we assume the period of latency to be under half an hour, preventive measures should be very promptly employed. The poison may be removed from the bitten part, or arrested before entering the general circulation or neutralized. The application of a cupping- glass, or excision, are calculated to withdraw the poison ; a ligature above the part affected, fulfils the second purpose; caustics, the actual cautery in- cluded, the third purpose. Of these appliances, that of cupping is most effi- cacious and practicable, if not the only one of value.J Diffuse inflam- mation consequent on the introduction of the poison, must be treated by free incisions and fomentations. Curative treatment has very little effect in overcoming the constitutional condition of utter prostration. Stimulants, such as brandy, wine, or ammonia must be freely administered. Arsenic, in large doses, has been recommended as a specific. Such is the " Tanjore pill," a famous Indian remedy. But its efficacy is doubtful and even perilous. Malignant Pustule or Charbon, is also communicated by contagion, the poisonous matter being caught directly from beasts, or their remains ; for the disease is not propagated apparently by the human species, from one individual to another. Local condition.—Soon after any accidental inoculation with the morbid matter, a stinging sensation is felt, and a red point appears, hardly elevated above the skin. Then, at this point, the cuticle rises into a blackish vesicle, which speedily runs into a slough, surrounded by an oedematous swelling, having a violet tinge, and spreading rapidly in all directions. Occasionally, neither vesicle nor pustule arises, only swell- ing. Such was the character of the disease in three cases observed by Lawrence.§ With obvious swelling, however, a sensation of tension, rather than pain, is experienced. Should several pustules arise, the disease is proportionately more perilous, and especially if situated on the neck or face ; for then the swelling may be so considerable as to threaten suffocation or congestion of the brain. Indeed, malignant pustule is not unlike carbuncle in appearance, but differs from it in being always the result of contagion. And this etiological consideration will always deter- mine the diagnosis. Constitutional Disorder.—A variable period having elapsed, the con- stitutional symptoms supervene. Fever, attended with pain over the stomach and vomiting, is soon succeeded by delirium and prostration. * Phil. Trans., 1810. t New York Med. and Phys. Journal, vol. ii. X Experimental Researches on the Influence of Atmosp. Pressure on the Blood in the Veins, and on the Prevention and Cure of the Symptoms caused by the Bites of Rabid or Venomous Animals. D. Barry, 1826. § Lancet, 1825-6, p. 127. 230 GENERAL PATHOLOGY AND SURGERY. The causative relation between the local lesion and this constitutional disorder is shown by their invariable sequence. The latter always follows the former; and, moreover, it is very doubtful whether the con- stitutional disorder can be induced by contact with the same morbid matter, unless succeeded by the formation of malignant pustule. This local lesion, therefore, would appear to be the only cause—the only mode of origin, of the constitutional morbid condition. The nature of the morbid matter itself is unknown, but it is developed in beasts affected with " contagious carbuncle." The poison may be im- parted by any accidental inoculation, in handling the animal when alive, or during the manufacture of hides, wool, &c. Malignant pustule is con- sequently most rife among butchers, tanners, shepherds, and wool-beaters. It may also be produced by eating the flesh of animals thus diseased. Instances in proof of this mode of production are cited by Wagner and Turchetti. Temperature and moisture have apparently some influence, for the disease is most prevalent in damp localities, and in wet autumnal weather. The morbid matter—whatever it be—retains its poisonous power for a long time; but the disease is probably not propagated by the human species, from one individual to another. Treatment.—Preventive measures are obviously suggested in accor- dance with the known etiology of this disease; although in the pursuit of certain avocations it may be difficult so to protect the hands and exposed parts of the body so as to escape contagion. Even then, however, this preventive opportunity remains; the progress of malignant pustule can generally be arrested at its commencement by excision or cauterization. Glanders is another disease derived by contagion from certain animals —the horse, ass, or mule—similarly affected. Inoculation of the human species is apt to occur by handling either animal when glandered; and the constitutional disorder thence arising may be briefly described as fever, resulting in the production of many inflammatory tumours in different parts of the body, which have a great tendency to suppurate and fall into gangrene. ToAvards the close of glanders, in 11 of 15 cases (Rayer), puriform mucus, mixed with blood, oozed from the nostrils; in 10 of these cases, the discharge came from one nostril only ; and in all cases the quantity was inconsiderable, some- times scarcely appreciable. The eyelids, also, are tumified, and secrete a thick viscid mucus. This disease runs its course in a period varying from a few days to many months. Its period of latency in man varies from two to eight days. Treatment.—I am not aware of any means whereby the progress of glanders can be arrested Avhen once inoculation has taken place, however early our intended preventive measures may be applied. If in this respect unlike the bite of a rabid animal, a snake-bite, or malignant pustule, glanders has at least one advantage—the disease can always be avoided. As bearing on the question of prevention, the early and exact diag- nosis of glanders in animals is important. It is communicated to man by an animal in a state of disease so obviously characteristic that the danger cannot be overlooked. Two varieties of this disease, in the horse, ass, or mule, are recognised by R. Williams. In gangrenous glanders, the animal immediately loses its spirits, and staggers; the nasal and conjunctival mucous membranes are beset with a number of red points, which at the end of twenty-four to HYDROPHOBIA. 231 forty-eight hours, become livid; the nostrils now discharging a yellow matter, streaked with blood. This condition lasts two or three days; then the nasal membrane falls into gangrene, and large ulcers form Avhere portions have sloughed. The discharge increases and exhales a foetid gangrenous odour; oedema of the nostrils, scrotum, and legs soon supervenes : at length, the nostrils being glued together, respiration fails, and the animal dies. In pustular glanders, the same general debility and fever are observable as in gangrenous glanders. The specific inflammation of the nasal membrane is an eruption of pustules, said to resemble con- fluent small-pox, followed by a copious yellow viscid discharge from one or both nostrils. After two or three days, these pustules ulcerate, some- times internally, so as to destroy the bones and cartilages of the nose. By absorption of the nasal morbid secretion, the sub-maxillary glands become swollen and tender, but only on the inflamed side of the head. Such enlargement is called the " kernels." GDdema of the nostrils, the sheath, and hind limbs succeeds, as in the gangrenous variety; and respiration failing, death ensues on the eighth or tenth day, at latest. Glanders is often accompanied with " farcy," and farcy often ends in glanders. Button farcy is characterized by inflammation of the cellular texture, forming tumours in different parts of the body; the head, neck, and ex- tremities, particularly the hind legs. In four or five days they soften and ulcerate. It is an inflammation of the lymphatic glands and vessels, usually beginning in the hind extremities, attended with lameness, and forming an irregular swelling of the limb, which at length ulcerates and discharges a sanious fluid. The period of latency in glanders affecting animals is generally short. Two asses—one about a year old, the other about a year and a half old, —were inoculated by Turner. In the former the maxillary glands became tender on the second day, and the discharge from the nostrils was established on the following day. In the latter the maxillary glands en- larged on the third day, but the nasal discharge did not appear until the sixth day. In a horse inoculated with farcy matter, the disease did not appear until the end of three months, and then precisely at the points of puncture. Gerard states that he introduced the matter of the discharge every day, at different times, into the nostrils of certain horses by means of a brush, and that the disease appeared on the seventh day, but in two others not until the thirty-second day. Fortunately, however, glanders is not an eminently contagious disease, either from one animal to another, or from this source to the human species; and its communicability from one human being to another is very doubtful. A case once apparently occurred in St. Bartholomew's Hospital:—a healthy nurse contracted disease from a glandered patient, and she died after a short illness, having every symptom of glanders. Assuming that glanders can be readily detected and distinguished from all other diseases, the prevention of its first propagation will consist in forthwith destroying the diseased animal from which, as the centre of contagion, it might spread. This preventive precaution is not alone suf- ficient protection to man or beast. The disease is communicable by fomites, as well as by direct inoculation from one animal to another. In this way, some of the discharge from the nose of a glandered horse having remained about the manger, rack, or partition of a stable, may be thaAved by the breath of a neAV horse, or introduced into the system in the act of 232 GENERAL PATHOLOGY AND SURGERY. nibbling or licking, whereby sound horses have speedily become glan- dered when put into a stable whence a glandered one had been taken weeks or months previously—thus reviving the disease, and with imminent peril to grooms and others in attendance. "Let, then," says Youatt, " the halters, head-gear, and bridles be burned; the clothes washed and baked ; the pails neAvly painted ; the racks and ranges thoroughly scraped, then washed well with soap and water, and afterwards with chloride of lime and water, in the proportion of a pint of the strong solution to a pail of water; let the walls be well scraped and washed with the chloride of lime and water, then well lime-washed; the floor be first thoroughly scoured, then sluiced Avith the chloride : and, with all these precautionary measures, every possibility of danger will be removed." DISEASES OF THE NERVOUS SYSTEM. CHAPTER XII. SHOCK OF INJURY.--COLLAPSE. Shock.—Symptoms, and Diagnosis.—Failure of the heart's action, or car- diac syncope, is the immediate effect of any sudden and violent impression on the nervous system. This failure of function is denoted by a thready, feeble, yet frequent and perhaps irregular, pulse; which is accompanied with pallidity, a cold clammy skin, haggard look, and lacklustre eye, great muscular prostration, soft sighing respiration, and, perhaps, some cerebral disturbance; symptoms which constitute the state known as Shock, or Collapse as arising from Injury. Other symptoms are excep- tional and occasional only. Hiccup, vomiting, relaxation of the sphinc- ters, attended with involuntary micturition and defalcation ; suppression of urine, convulsions, and stupor. It thus appears that in this state of functional suspension, both the nervous and blood-vascular systems are overwhelmed, involving possibly, all other functions; but, as the shock of Injury, the nervous system is primarily affected, and thence the vascular system; thus differing from cardiac syncope consequent on haemorrhage. A great physiological rela- tionship underlies the pathology of Shock;—namely, that while the action of the heart is independent of the nervous system, it is much influenced and even arrested by any impression through that system. Not unfre- quently, however, with Injury, both modes of origin,—nervous suppres- sion and loss of blood, co-operate. Causes—Injuries of all kinds—e.g., incised and lacerated Wounds, Burns, Fractures, and Dislocations—are attended with Shock ; and accord- ing to their extent as involving the nervous system, and their persistence as causes in operation. A burn, superficial in itself, but extensively in- volving a considerable cutaneous expansion of the nervous system, will cause more extreme shock than a far deeper burn of limited nervous con- sequence. Unreduced Fractures and Dislocations continue to operate, by laceration and pressure, on the nervous system. But injuries of organs, abundantly supplied with nerves, or in intimate relation with the SHOCK OF INJURY.—COLLAPSE. 233 nervous system, are equally influential. Thus, crushing of the testicle, or lesion of an internal organ, may prove fatal. Simple shock, without any apparent structural damage, may be equally deadly. A blow, for example, over the epigastrium; or pain, intense and prolonged; a stroke of lightning or exposure to cold. Certain poisons, probably, have an action resembling Shock; such are powerful sedatives, as tobacco, and powerful purgatives. Mental emotion may operate in like manner. Fear, or bad news, will cause the heart to sink in a moment, accompanied with the pallor of col- lapse ; Avhile, a depressing passion, such as grief, weighs it down more permanently. Predisposing conditions are, perhaps, very influential. Impressibility to the causes of Shock is, however, not an indication of its continuance; but generally inversely proportionate. Thus, shock may be easily occa- sioned, yet soon pass off, as in youth ; or not so readily occasioned, and yet persistent, as in old age. Premature age, by intemperance or sexual excess, is peculiarly unfavourable. Constitutional susceptibility is well marked, in the shock of some individuals; but it requires all the expe- rience and judgment which the Surgeon can bring to his aid, to foresee this peculiarity. I remember removing a great toe-nail, under the local- anaesthetic influence of ice and salt; the patient being a robust, ruddy- complexioned young woman. She sat up during the operation looking at her foot, and experienced no pain then, nor much afterwards. Yet no sooner had the circulation in the toe returned, than she became blanched and cold, and subsequently fainted—alarmingly several times. Terminations.—(1) A fatal termination may ensue almost imme- diately, and unexpectedly. I have seen a patient with severe compound fracture just removed to bed, restlessly attempt to raise himself once or twice, and then drop dead on the pillow. The heart's action is paralysed through the impression on the nerA'ous system. After death, the heart is found engorged with blood; all its cavities being distended, especially the right auricle and ventricle. The venous system, generally, is similarly distended. Coagulation has taken place to some extent, but imperfectly ; a considerable portion of the blood remain- ing fluid, while the clots are loose and dark. Sometimes the blood is altogether fluid. Rigor mortis commonly occurs, and sometimes very strongly. A significant fact is the accumulation in the stomach, of any food Avhich may have been taken, and that it has undergone little or no change; thus indicating the suspension of digestion, in common with other functions which can be observed during life. I have also fre- quently found the intestines comparatively empty, and singularly en- larged, owing apparently to atony of their muscular coats. Beyond these appearances there is a remarkable absence of any discoverable lesion apart from the injury itself, which has occasioned the shock. Consider- ing the known dependence of all function on structure, it is highly probable that some molecular disintegration of nerve-tissue has occurred, Avhich has hitherto eluded observation. This would not be inconsistent with the speedy recovery in many cases, by any such structural disorgani- zation having returned to a healthy state. (2) Reaction.—A natural restorative effort commonly ensues, in a period varying from a few minutes to thirty-six or forty-eight hours, or more. This reaction, as it is termed, of course implies the revival of those functions Avhich have been temporarily suspended. The balance 231 GENERAL PATHOLOGY AND SURGERY. of the circulation is regained, the pulse acquiring force and fulness, and losing its frequency and irregularity. With it warmth returns, and the colour of the living body reappears. Respiration becomes more per- ceptible, prostration is less marked, the individual evincing some in- clination to turn from the supine posture, and the cerebral obscurity clears off. Ordinarily, I think, reaction is not a continuous restorative effort; but slight retrogressions towards collapse occur, followed by reactions progressively more and more complete; and it is by this series of ebbings and flowings, that the balance of the circulation and other functions is at length regained. If revival be incomplete, a mixed state of exhaustion, with reaction, prevails. Prostration with excitement—as this state was first named by Mr. Travers—is distinguished by a rapid bounding pulse, but weak and liquid. The skin is hot and the face flushed, but there is still a haggard expression. The breathing is hurried, and irregular, there is much restless tossing about, and perhaps spasmodic action of the muscles, with great debility, and the mind becomes excited and bewildered. The patient noAv dozes off, then flickers up, as it were, suddenly, with an agitated and tremulous manner, only again to wander, and again arouse. At length frenzy, possibly, subsiding in coma and re-exhaustion, with a cold clammy sweat, ends in death; or ultimately, reaction prevailing, the pulse regains its force, loses its frequency, and the healthy status is slowly re-established. Remote constitutional consequences are said to occur after the shock of injury ; resulting perhaps in sudden death, some weeks or months after apparent recovery. Hodgkin and James have directed attention to these consequences; but it is very difficult to connect them as such with the original shock. The prognosis of shock is always precarious and uncertain. It will depend very much on the causes, immediate and predisposing, already mentioned. And here individual predisposition is a highly important criterion; and especially the natural calmness and hopefulness, or the irritability and despondency, of a patient. Watchful nurses recognise these distinctions in their prognosis, as well as surgeons. The explana- tion is obvious, that mental dispositions are not only predisposing, but also persistent and therefore maintaining causes of shock. Persistent conditions of bodily injury are likewise unfavourable. Extent of injury indicates rather the immediate intensity of shock, than the probability of its continuance. Treatment.—This also should have reference to the cause or causes of shock. Some are slight and transient, and thence reaction soon follows. Others again are more severe and perchance persistent; whereby the shock being proportionately more intense and lasting, reaction is delayed, and imperfect. The removal of any cause still in operation is, therefore, obviously of primary, and in a measure, of preventive con- sequence. Hence, the reduction of fracture or dislocation, of strangu- lated hernia, and even the amputation of a severely injured limb, are of vital importance, in the treatment of shock. Remedial measures take effect in proportion to the natural tendency to reaction, and this—apart from the continued operation of causes—is not immediate. The patient should be placed in the recumbent position, and stimulants administered to further aid the returning circulation. SHOCK OF INJURY.—COLLAPSE. 235 Warm tea for children, brandy or ammonia and water for adults, may be given, provided the patient can swallow; otherwise, with insensibility, the fluid may pass into the larynx and cause suffocation. Watching the effect on the pulse, stimulants must be repeated from time to time as occasion requires. Volatile ammonia held to the nostrils is temporarily restorative, but it may be thus administered when fluids cannot be swallowed. Then also, a stimulating enema, of turpentine for example, will be an advantageous mode of stimulation. In all cases, warm blankets, hot bottles to the feet and epigastrium, and perhaps galvanism, are available and effectual. The possibility of over-stimulation, by any of the means employed, must not be overlooked; remembering that sensation, for a time, is in abeyance, we should, as Professor Miller expressed it, "feel for the patient." In apparently hopeless cases, artifi- cial respiration, patiently continued, may be resorted to with success. Opening the external jugular vein, is recommended by Mr. Savory, in consideration of the engorgement of the right side of the heart and venous system. Collapse from the loss of blood by haemorrhage from any cause, suggests the employment of " transfusion," as the special means of meeting this emergency. Nourishment also, to supply the loss of blood, is a more immediately urgent requirement than in ordinary nervous shock. Excessive reaction must be met by opiates rather than blood-letting ; the fever being nervous more than inflammatory. The substitution of light nourishing food for mere stimulants, will be found advantageous; for there is still a strange mixture of exhaustion with such reaction. Prostration with excitement,—or the more pronounced phase of this condition, requires similar treatment. The quantity of opium borne with impunity, and eventually proving remedial, is often surprising. Grain doses of solid opium or equivalent doses of the tincture, may be administered repeatedly, at intervals, according to the symptoms; and with stimulants, in kind and quantities, also according to the symptoms, and the previous habits of the individual. Nourishing food should, as soon as possible, aid or supersede these more immediate resources. Not unfrequently, however, any food is almost rejected by a sort of hiccupy vomiting, a symptom which is in itself distressing to the patient. Small pieces of ice swallowed occasionally may afford some relief; and hydro- cyanic acid, or creosote, are sometimes more useful. The question as to the performance of a Surgical operation during Shock, is determined by two considerations;—the persistence, or not, of any cause in operation, as, for example, a bad compound fracture ; and, secondly, the pathological fact, that the nervous system and circulation already in the state of Shock, is less susceptible of further shock than after reaction. An almost immediate surgical operation thus forms part of, and joins issue Avith the injury, for which it is performed. After that period of juncture, it is better to make a compromise with the vital powers, by waiting for incomplete reaction. Chloroform, is detrimental, in proportion as Shock prevails, and equally useless, owing to the comparative insensibility of the patient. 236 CHAPTER XIII. TETANUS. Tetanus (rdvu), to stretch) signifies a violent and involuntary contraction of the voluntary muscles, attended with severe pain and rigidity. Symptoms, and Diagnosis.—The spasmodic contractions having com- menced, never entirely relax throughout the course of the disease ; they are tonic, thus distinguishing them from intermittent or clonic spasms in ordinary convulsions, as in hysteria or apoplexy; and complete con- sciousness is retained to the last, this additional characteristic distinguish- ing the tetanic from clonic spasms in epileptic convulsions, and from those of hydrophobia Tetanus approaches and proceeds by the following series of spasmodic contractions, each persisting in the order of their succession. Stiffness is first experienced about the root of the tongue, which is usually re- tracted. Articulation therefore is imperfect. A sense of painful rigidity in the posterior muscles of the neck, and some difficulty in moving the jaw, are soon experienced. If the jaw be fixed, and tetanus proceeds no further, it is known by the name of trismus, or lock-jaAv. Generally speaking, other sets of muscles become involved. The facial muscles are convulsed ; the angles of the mouth being drawn up, presenting a peculiar expression, the " tetanic grin " risus sardonicus. Deglutition is accomplished with great difficulty, and fluids are convulsively ejected Avhen any attempt is made to swallow them. In this particular, tetanus resem- bles hydrophobia. Even the sight of fluids may occasion dread,—another point of resemblance. Yet in no other respect is there any similarity be- tween these diseases. No foaming at the mouth of a thick mucus, with con- stant movement of the jaw to extricate it, is ever Avitnessed, as in hydro- phobia. Other peculiarities supervene. Pain strikes through the body from the ensiform cartilage backwards to the spine, and being accompanied with intense spasm of the diaphragm, occasions agonizing dyspnoea, which has been compared to that of hydrophobia. Very soon the muscles of the back contract, and with such violence that the body is drawn into the form of an arch resting on the head and buttocks (opisthotonos) ; or the abdominal muscles contracting, become as hard as a table, and draw the body forward (emprosthotonos). During these spasms, the rectus muscle has been torn with the violence of its contractions. The body is some- times bent to one side (pleurosthotonos). Next in order, the muscles of the lower extremities are involved; and lastly, those of the upper, ex- cepting the fingers, which generally remain moveable to the last. The tongue also is rarely involved, although it may be thrust violently against the teeth and be much lacerated. Such is the ordinary course of events in Tetanus. They constitute one continued manifestation of spinal excito-motion, without suspension of the cerebral functions; but, as would be expected, the tetanic spasms— violent and continuous—provoke general disturbance of the organic functions. Thus, the respiration being much embarrassed, the heart beats more quickly and forcibly, giving to the pulse similar characters; TETANUS. 237 but they are eventually succeeded by feebleness and irregularity. The urine is perhaps scanty and high-coloured, and is sometimes retained or voided in small quantities, while the skin pours forth abundantly a sour- smelling SAveat. Lastly, obstinate constipation is a constant and signi- ficant symptom throughout this disease; and should an evacuation occur, it is singularly offensive. "I remember," says Abernethy, "on one occasion, asking an old nurse Avhat sort of evacuations had come from a tetanic patient, who for a week had no relief from the bowels ; ' Lord, sir,' she replied, ' they are not stools, they are sloughs.'" The diagnosis of tetanus is not always clear. I have already noticed how it differs from hydrophobia, epilepsy, apoplexy, and hysteria. But it may resemble the latter disease. Hysteria with spasm.—Hysterical tetanus may occur in females, and present a wonderful likeness. No fatal case is recorded. According to Dr. Copland ; in females, trismus or subacute tetanus may assume an hysterical character, or hysterical symptoms may be associated with the tetanic, the disease being really tetanus and occasioned by an injury. Certain drugs produce convulsions, resembling those of tetanus. Strychnia, is thus specially deceptive. But the tetanic spasms, produced by strychnia, are remittent or intermittent, and subside entirely as the poisonous influence passes off, or kill in the first onset if the dose or doses be sufficiently potent. All these points of distinction were observable in the case of Cook, and were successfully urged against Palmer in the celebrated trial for the murder of that man. Morphia sometimes pro- duces convulsions, but they are epileptiform, and long in their develop- ment. Varieties.—Sometimes trismus and general tetanic twitches supervene on continued prostration, and remaining associated with it, constitute a variety of "prostration with excitement." The excitement is tetanic. Such Avere the phenomena I observed during the course of a severe burn, under the care of Dr. A. Marsden in the Royal Free Hospital. The burn extended over the toes and instep of the right foot and lower part of the leg. Its depth was to Dupuytren's fifth degree. The annular ligament Avas destroyed, the interior of the ankle-joint exposed, as also were the carpal bones, and the nails Avere burnt away. An attempt was made to save this foot, Avhich would, I believe, have proAred successful, with the removal of portions of bone; but the patient, a middle-aged woman, was fat and flabby, and a hard drinker. Prostration continued, and in a few days partial trismus, Avith tetanic twitches of the arms and hands, set in. The patient's mind Avandered; she frequently raised her head, uttered a few words, and then dropped on to the pilloAV, turning her eyes right and left with restless agitation. I suggested to Dr. Marsden, Avho was good enough to ask my opinion, that amputation might be deferred, and that a grain of opium, Avith ten grains of castor, be given every four hours. The trismus never became complete, nor the tetanic twitches more general; but this condition lasted for more than a week, Avith continued prostration, Avhen the Avoman died exhausted. In other cases of continued irritation pure tetanus supervenes. A man died of universal tetanus in a feAv hours after an oblique fracture of the thio-h-bone, which penetrating the rectus muscle, was continually playing through the belly Avith a see-saw* motion. A man having a simple fracture of the femur, and who appeared to be doing Avell for four days, Avas seized on a sudden with lock-jaw, and died in three days of acute * Constitutional Irritation. A further Inquiry, 1835. Travers, p. 292. 238 GENERAL PATHOLOGY AND SURGERY. universal tetanus. Examination showed that the upper fragment of the bone, obliquely fractured, had perforated and left a detached spiculum of considerable size transfixing the vastus internus muscle.* Certain varieties are noticed by Mr. A. Poland, in his elaborate article on Tetanus.y Spasms primarily attacking the muscles of the part injured, instead of the muscles of the jaw. Two cases are mentioned, both of which were fatal. In the one, two months elapsed, before the first symptoms occurred, a neuralgic affection of the muscles of the ball of the thumb, without any appearance of inflammation. The injury, originally, was a lacerated wound of the fleshy part of the thumb, by a splinter of teak-wood, which had transfixed the part. This was withdrawn at the time, and the wound healed soundly. But, after death, two pieces of splintered teak were found imbedded in the abductor muscle, and resting on a branch of the radial nerve. The other case, was occasioned by a blow of a schoolmaster's cane on the hand. In this instance, both pain and spasm commenced in the injured part; followed by a gradual spasmodic contraction of the flexor muscles of the hand, drawing the fingers into the palm, and subsequently extending to the arm and other parts. Absence of pain was characteristic of one case, even to the last moment of existence. The cramps were accompanied by a tingling and agreeable sensation, with a strong tendency to laughter. Special affection of the muscles of the face and eye, was noticed in three cases, simulating ptosis in two of them. The muscles of the eye are sometimes affected; the eye-ball being fixed and drawn slightly inwards. The pupil may be contracted or dilated. Cerebral complications are very rare ; but delirium may supervene towards the close of tetanus. Epilepsy is another quite exceptional complication, in a patient subject to this disease. Screaming and convulsions, apparently not epileptiform, may occur. Motor-paralysis occurred in two cases of the seventy-two, in Guy's Hospital, from which the above results were gathered. Remission of the symptoms is extremely rare, yet it has been noticed in several instances. In one case—according to Dupuytren—tetanus subsided for twenty-eight days, and then returned after an exposure to cold. All these anomalous forms of tetanus are worthy of notice, as bearing on the, possibly obscure, diagnosis of this disease. Pathology.—Until recently, the pathological anatomy and interpre- tation of the functional or pathological phenomena of tetanus, were in- volved in great obscurity. And although the essential nature of this disease may yet require further elucidation, and especially by a more ex- tensive assortment of post mortem examinations ; the original researches of Mr. Lockhart Clarket; have brought to light a series of structural changes in the spinal cord, which are of the highest importance. In six cases, these changes may be summarily stated as follow; and, apparently, in the following order of succession. No morbid deposit nor any appreciable alteration of structure takes place in the walls of the blood-vessels of the cord; but the arteries are frequently dilated at short intervals, and, surrounded, sometimes to a depth of double their diameter, by granular and other exudations; beyond and amongst which, the nerve-tissue, to a greater or less extent has undergone certain changes. In the first stage, softening of this * Constitutional Irritation. A further Inquiry, 1835. Travers, p. 315. f System of Surgery. Ed. by T. Holmes. % On the Pathology of Tetanus, 1865 : Med.-Chir .-Trans. Lond. TETANUS. 239 tissue ; secondarily, granular disintegration, the tissue becoming softer or semifluid, and more transparent. Ultimately, the reduction of the tissue to a fluid state. This fluid at first, is more or less granular, holding in suspension the fragments and particles of the disintegrated substances, but in many places, it is perfectly pellucid. The blood- vessels also share in the disintegration of the part, and commingle with their ensheathing granular exudation. Thus a general softening and disintegration of structure has taken place. A fluid area, of considerable size, may occur at a single spot, and extend to the surrounding tissue ; or at several spots, which advancing, coalesce between irregidar masses of the tissue, or portions separating, are left as islets in the fluid. This process of destruction affects the grey substance of the cord; perhaps its central part. The same lesions of the cord are found in paralysis. But they are commonly unaccompanied by spasm, during life. Tetanus therefore probably differs only from that disease in being associated with a morbid condition or injury of some of the peripheral nerves. A marked con- gestion and inflammation of a nerve connected with, and leading from, a wound that has occasioned the disease, is a local morbid condition, which Mr. Erichsen states he has never found wanting ; the vascularity, which may be very intense, often extending up the neurilemma to a considerable distance. It would therefore appear—observes Mr. Lockhart Clarke—that this condition or injury of the peripheral nerves is the determining cause of the phenomena, and that the spasms of tetanus depend on the conjoint operation of two separate causes. First, on an abnormally excitable state of the grey nerve-tissue of the cord, induced by the hyperaemic and morbid state of its blood-vessels, with the exudations and disintegrations resulting therefrom. This state of the cord may be either an extension of a similar state along the injured nerves from the periphery, or may result from reflex action on its blood- vessels excited by those nerves. Secondly, the spasms depend on the persistent irritation of the peripheral nerves, by which the exalted excita- bility of the cord is aroused ; and thus the cause which at first induced in the cord its morbid susceptibility to reflex action is the same which is subsequently the source of that irritation by which the reflex action is excited. In so-called idiopathic tetanus, arising from exposure to cold and damp, it is probable that the morbid condition of the blood-A-essels of the cord, results from changes in the state of the peripheral nerves, which may act through reflex action or otherwise. Associated with these essential changes of structural condition in tetanus, others which are apparently incidental, may be noticed. A marked vascularity of the membranes of the cord and engorgement of the veins within the vertebral canal. In a case of strangulated femoral hernia, for which I operated, all went on favourably for a week, and the incision had nearly healed; Avhen suddenly the most violent tetanus set in, beginning Avith locked-jaw, proceeding to appalling opisthotonos, and terminating fatally on the fourth day, by which time the wound had re- opened and become gangrenous. I carefully examined the cerebro-spinal axis throughout its whole extent. The intra-spinal veins Avere gorged with blood, but not those of the cord itself. The intestines have been found much inflamed in several cases ; and in two, a yellow, Avaxy fluid, 240 GENERAL PATHOLOGY AND SURGERY. of a peculiar offensive odour, covered their internal surface.* The pharynx and oesophagus may be much contracted, and contain a viscid reddish mucus.f The muscles are usually rigid ; sometimes ruptured, and sometimes there is no rigidity. Causes.—Injuries of all kinds may possibly be followed by tetanus. From the most trifling scratch to the most terrible laceration, tetanus may ensue, yet not with equal probability. But it occurs most frequently from those injuries which in point of their extent or persistence, by con- tinued nervous irritation, are most conducive to the continuance of Shock. I have already noticed that variety of " prostration with excitement," in which the excitement is tetanic. Burns are thus peculiarly liable to in- duce tetanus. Punctured, lacerated, and contused wounds, particularly of the hand or thumb, of the sole of the foot or of the toes, have a direct tetanic tendency. Unyielding fibrous textures are peculiarly revenge- ful in this respect. Compound fractures and dislocations, rather than the simple form of these lesions, are threatening complications; and more so, if the fracture be oblique and playful among nerves and muscles, or if the dislocation be that of a ginglymoid joint, as the thumb. Gunshot wounds, involving possibly other forms of injury, rank high as causes. Amputation, as in the thigh, or the removal of a breast or testicle, are known causes. So also minor operations; e.g., for fistula in ano, liga- ture of piles, extraction of a tooth, cupping, the irritation of a seton. Diseases ; e.g., gangrene, ulcer of the leg, a guinea worm under the in- tegument, caries of the tibia. In obstetric practice ; abortion, retained placenta. The condition of a wound, at the time of tetanus, seems to have little relation to the disease. Thus, in one case, recorded by Hennen, cicatri- zation was completed on the same day that life terminated; and Dr. Elliotson observes, that the disease has sometimes declined and ceased, although the wound daily grew worse. Period of probation or incubation, between the local injury and the commencement of tetanus. This period has its average limits of duration. As extremes may be mentioned a few hours, or some days,— the fifth to the fifteenth day, and up to the twenty-second day ; the average being the tenth day. Tetanus arising from any of the foregoing forms of Injury, is deno- minated traumatic; as distinguished from tetanus arising from other causes, whether external or internal, unconnected with Injury, the disease being then named idiopathic. But this distinction relates to origin only, and is, moreover, not always definite. Such causes include, exposure to cold and damp, currents of air hot or cold, bad ventilation or atmo- spheric poisons, irritation of worms, sudden suppression of the perspira- tion, of the catamenial or lochial discharges, or of acute diseases, and terror or anxiety of mind. Predisposing causes.—The disproportion, in many cases, between the local injury and the development of tetanus, as well as the varying period of probation intervening ; are probably due to the influence of predisposition. A scratch of the thumb by a broken plate, proved fatal in a quarter of an hour ; and in other cases, a slight blow, as by a whip- lash under the eye, although the skin was unbroken, has been followed by tetanus. In such cases, some predisposing condition probably was * Med.-Chir.-Trans., vol. vii. p. 475. t Me"m. de Chir. Militaire. Larrey, t. iii. p. 287. TETANUS. 211 also in operation. Age.—No period of life is exempt; but, perhaps, infancy and middle age are. most subject. In infants, the disease—then named trismus nascentium—occurs from seven to fourteen days after birth. It may terminate fatally in ten or thirty hours, or life be prolonged to eight or nine days. Its origin is apparently traumatic; namely, from division of the umbilical cord, or irritation of the intestines by meconium, or worms; or it has been traced to unwholesome food, bad ventilation, or exposure to currents of air. It occurs very frequently in the Tropics, occasionally in Europe. Sex.—Males are most liable to tetanus, in a ratio of about seven to one female. Habits of life seem to have little influence, the disease attacking equally the temperate and the intemperate. Constitu- tional susceptibility is not apparent; individuals of any temperament being equally liable. Climate.—The disease is more prevalent in Avarm climates and in marshy districts; also near the sea-coast than inland. Never- theless, season of the year is said to have no influence on the occurrence, or the mortality, of tetanus.* Course, and Terminations.—(1) Generally, tetanus proceeds in a con- tinuous course of development; affecting the muscular system, in the order already mentioned, and terminates fatally. About the second or third day, as acute tetanus ; the ninth or tenth day, as chronic tetanus. But the former is commonly fatal, the latter far less so. The mode of death, is, commonly, during a paroxysm affecting chiefly the muscles of the larynx; which, by complete closure of the glottis, produce almost instant suffoca- tion. The slightest attempt to move, or to swallow, seems to excite this issue. I witnessed it in one case, during the attempt to swallow an opiate pill. A sudden jerk of the throat occurred, a suffusion of the face, succeeded by deadly pallor, and all was over. Exhaustion, is another, but less frequent mode of death. (2) Recovery is preceded by a gradual subsidence of the tetanic contractions ; and this happy issue is generally granted to the few who survive the tenth day. It is also stated, that the longer the period of probation, before the commencement of tetanus, the greater is the proba- bility of recovery. Conversely, the shorter the period of probation, as well as the more rapid the progress of the disease, the more surely fatal is the issue. But this, perhaps, general rule, is exceptional in many cases of rapid progress, after the probationary period of ten days. Prognosis.—The prognosis of tetanus will be guided by a due con- sideration of the conditions which chiefly determine its tendency to a fatal issue, or to recovery. They are, principally, the traumatic or idiopathic origin of the disease, the influence of predisposition, as evinced by its speedy accession, and its acute or chronic progress. Treatment.—Preventive measures are the most, or only, effectual re- sources. This implies the early detection and removal of any persistent causes in operation; such intervention necessarily having reference to local causes, rather than to constitutional causes, which mostly elude detection or are beyond control. Hence prevention is practicable mostly in tetanus of traumatic origin. Happily, also, the intervening period of probation is available for surgical interference. Wounds may be thoroughly cleansed of foreign bodies, and the parts adjusted. Swelling, under tight, unyielding textures, may be relieved by incisions. Burnt surfaces may be effectually protected from the influence of the air. Most compound * Guy's Hospital Reports, vol. iii. ser. iii. R 242 GENERAL PATHOLOGY aiSu SuRGERi. fractures and dislocations can be soon detected, reduced and kept in position. Are there any other causes possibly in operation besides the local injury? Constipation is constant and significant; significant, partly because constant, and also because of the peculiar matter voided when an evacua- tion does occur. More than forty years since, Abernethy proposed for the consideration of surgeons this question—whether the disordered con- dition of the digestive organs, established during the irritative state of the wound, may not be the occasion of tetanus, when that irritation has itself ceased ? If, he adds, this proposition be established the very im- portant conclusion follows, that by preventing the disordered condition of the digestive organs, you would prevent tetanus. No purgative medicines that I know of for this purpose are specially serviceable. The foregoing preventive considerations are most important; for every practical surgeon will concur in acknowledging the hopelessness of all known medicinal treatment when the disease is fully developed; and, in such case, the equal inutility of any surgical operation to relieve the symptoms of, much more to cure, this deadly disease. Remedies, then, there are none, at present known. The long list of medicinal and surgical resources which have been successively tried, and have failed, Mr, Poland thus enumerates. Antiphlogistics, including blood-letting, purgatives, calomel, antimony, colchicum, &c, have been extensively used; alteratives, as the various preparations of mercury, large doses of fixed alkalies, solutions of arsenic, &c.; diuretics, in the form of tincture of cantharides, oil or spirits of turpentine, given in fre- quent and large doses, so as to irritate the urinary passages, or to occasion bloody urine; sedatives, such as digitalis, tobacco, nicotina, hydrocyanic acid, aconitina; anodynes and narcotics, as opium, morphia, belladonna, cannabis indica, ether and chloroform internally and by inhalation ; stimulants and antispasmodics, including musk, ammoniacum, camphor, turpentine, assafoetida, castor, wine and other stimulants; tonics, such as quinine, bark, strychnia, iron, zinc, &c. ; hygienics and dietetics, as sup- port, milk-diet, &c. ; injections into the veins of solutions of opium stramonium, &c.; tracheotomy and laryngotomy. This list of variously accredited remedies, is at least suggestive of what to avoid, as useless, or perchance, noxious, in the course of tetanus. Chloroform may relax the spasms, for a while, and thus relieve pain. It had this temporarily palliative influence in the overwhelming case after strangulated femoral hernia, which I had reduced by operation. PART II. SPECIAL PATHOLOGY AND SUEGERY. DIVISION I. INJURIES AND DISEASES OF TEXTURES. SKIN AND SUBJACENT TEXTURES. CHAPTER XIV. WOUNDS :--INCISED WOUND. WOUNDS OF arteries and veins. A Wound is a solution or breach of continuity of the soft tissues, sud- denly produced, in any part of the body. Such lesion may be effected by various instruments of a cutting, tearing, or puncturing, character. Hence, Wounds are commonly distinguished, as Incised, Contused and Lacerated, and Punctured. Gun-shot AYounds are also contused and lacerated. Poisoned wound is characterized, not by the nature, and still less by the extent, of the lesion itself, which may be only a slight punc- ture ; but, by the accompanying introduction of some poisonous matter, whereby the constitutional disturbance becomes of far greater conse- quence than the local lesion. Such are stings of bees, wasps, hornets; snake-bites ; bites of rabid animals, giving rise to hydrophobia; and dis- section wounds. Excluding, therefore, poisoned wounds; Wounds differ most signifi- cantly in their relation to the laws of Reparation. Incised wound has a natural tendency to undergo repair, or to heal, by primary adhesion, when its surfaces are placed in contact; all other wounds, in proportion as they are contused or lacerated, have a natural tendency to sloughing, and then to undergo repair by the slower process, on an open surface, of suppura- tive granulation and cicatrization. Incised Wound. An Incised Wound is a solution of continuity of the soft textures; suddenly produced, and with even division of the tissues. The former character distinguishes this lesion from a breach resulting from ulcera- tion ; the latter character defines it from a contused wound. Symptoms.—Pain, and haemorrhage or effusion of blood, in various de- grees, accompany the division of nerves and blood-vessels ; and the wound opens or gapes more or less, according to the elasticity, muscular contrac- tility, and weight of the parts. The former symptoms are not peculiar to this, or any other kind of Injury,—thus illustrating the insufficiency of r 2 244 SPECIAL PATHOLOGY AND SURGERY. Functional Symptoms in Diagnosis [P. p. 169] ; while absence of the latter symptom—gaping of the wound—is the negative distinction of a subcutaneous incised wound. But this lesion is, moreover, not exposed to the action of the air ; a peculiarity of essential importance—as determining the course of a subcutaneous wound in respect to its more speedy reparation. Cause, and Effects of Incised Wound.—Incised wound is produced by the edge of any sharp cutting instrument, as a knife ; not by a blunt or a pointed weapon. Its effects are essentially local, in relation to the function of the part wounded; but the lesion produces constitutional disturbance in propor- tion to the implication of nerves and blood-vessels, and to the functional importance of the part in the system. Hence, the Shock of injury to the nervous system ; the Collapse arising from profuse or persistent haemor- rhage ; and the serious functional disturbance arising from wound of an internal organ, as the lung or intestine. Reparation.—Incised wound tends to undergo the reparative process of healing by primary adhesion, unaccompanied by inflammation; when the surfaces of the wound are in contact. But an incised wound may heal by other modes of reparation, under different circumstances. It will therefore be necessary to here describe all these modes of healing, which are four in number; although the latter two will be found to pertain more especially to Contused and Lacerated, or open, Wounds. The inherent power of organization which the materials for reparation, possess, must first be noticed; and in virtue of which all other kinds of Injury undergo repair. Reparative Materials.—Coagulable lymph, and, possibly, blood are the materials supplied; and their reparative power is exhibited by the organi- zation they both undergo, spontaneously. John Hunter, so far as I know, first advocated the possibility of blood undergoing this change; and it was with him the mode of " union by the first intention."* Sub- sequently, the organizability of blood was disputed by Mr. Traversy and other observers. Now, however, it is amply confirmed by the microscopic observations of Zwicky,| Paget,§ and Dr. W. T. Gairdner,|| not to mention others. I allude to observations such as these:—the organiza- tion of blood effused in serous sacs, particularly in the arachnoid ; of clots in veins being converted into fibrous cords, or having evinced less con- structive power, degenerating into phleboliths; clots forming distinct tumours in the heart and arteries; and the clot above a ligature on an artery becoming part of the fibrous cord which constitutes the impervious portion of artery. Mr. Paget thus estimates the function of blood in the repair of in- juries:—1. It is neither necessary nor advantageous to any mode of healing. 2. A large clot, at all exposed to the air, irritates and is ejected. 3. In more favourable conditions, the effused blood becomes enclosed in the accumulating reparative material; and while this is organizing, the blood is absorbed. Lastly, it is probable that the blood may be organized and form part of the reparative material; but even in this case it probably retards the healing of the injury. * Blood. Inflammation and Gun-shot Wounds, p. 193-4. t Physiology of Inflammation, and the Healing Process, 1844, p. 162. \ Die Metamorphose des Thrombus, 1845. § Surgical Pathology, vol. i. 1853, p. 174. || Edinburgh Monthly Journal, Oct. 1851, p. 392. INCISED WOUND. 245 Mr. Paget then traces the process of organization which coagulable lymph undergoes. Fibro-cellular or connective tissue is formed, but in either of two different ways, or by both processes of development simul- taneously ; and the particular mode of lymph-development is determined chiefly by the circumstance of exposure or not to the air. Lymph effused for the repair of open wounds generally developes itself into fibro-cellular tissue, through nucleated cells, which elongate into fila- ments ; while that effused for the repair of subcutaneous wounds as gene- rally developes itself into this tissue, through the medium of nucleated blastema—by the nuclei developing themselves into fibres (Henle), or by the blastema itself undergoing fibrous transformation (Paget). The same state of organization—fibrous tissue—is thus attained, by either of these different processes of self-development, or, as I have said, by the association of both in some, probably many, instances of reparation. Modes of Reparation.—Wounds may heal in one or other of four different ways, first clearly distinguished by Macartney; and subject to certain modifications, the distinctions he drew are still accurate. First. Immediate union, without any intervening substance, such as blood or lymph. (Union by the first intention, and through the medium of blood—Hunter). Secondly. Union by the medium of coagulable lymph, or a clot of blood—mediate by lymph or blood. (Union by adhesion, or adhesive inflammation—Hunter. Union by first intention, as now commonly understood. Primary adhesion—Paget.) Thirdly. Reparation by suppurative granulations. Fourthly. Healing under a scab. (The modelling process of Mac- artney ?) Each of these processes of healing claims some further notice, and in reference to the power of reparation indicated thereby. (1) Immediate union is effected only under certain circumstances. Incised wounds will thus unite when the cut surfaces are immediately replaced in close contact, so that no substance of any kind intervenes. The blood itself is pressed out of the wound, the divided blood-vessels and nerves are brought into perfect contact, and reunion ensues by the opposed surfaces simply groAving together. This process of repair is very speedy. It will take place in two or three days; possibly in almost as few hours. No intermediate substance exists in a wound thus healed; consequently no cicatrix or mark remains. Nature undertakes and may accomplish the immediate union of any incised wound, irrespective of its extent, provided only the conditions mentioned are fulfilled. Thus, divided nerves may reunite, as manifested by the recovery of sensation or other function peculiar to them. But restoration is, gene- rally, very slowly effected. In a case under my care at the Hospital, the tongue was severed by an incised Avound, extending nearly through the substance of that organ, which hung by a mere shred on the left side ; dividing the gustatory and hypoglossal nerves on both sides. The divided portion having been promptly replaced and secured, in even con- tact Avith the root, complete reunion took place ;—the tongue slowly recovering the power of motion and the sense of taste. (2) Primary Adhesion.—A period of reparative inactivity, perhaps of short duration, succeeds the injury; during Avhich the divided tex- tures are indisposed to unite, although placed in apposition. But this condition of apparent inactivity may partly be due to interception of the 246 SPECIAL PATHOLOGY AND SURGERY. process of reparation; either by the presence of some foreign body between the cut surfaces, or from continued haemorrhage. The process begins whenever the textures are glazed over, thus sealing the blood- vessels. This appearance of the wound denotes either the previous exudation of reparative lymph, or the coagulation of a thin layer of blood, just sufficient for adhesion. Reparation then commences. Either form of reparative material—lymph or blood in small quantity—undergoes organization, apparently by virtue of its own inherent formative power. Fibro-cellular tissue thus produced, consists of cells lengthened and attenuated into fibres. (See Fig. 2.) This constitutes an intervening layer of texture as the permanent bond of union, thence named connec- tive tissue, and which presents externally the appearance of a linear cicatrix, or scar. Fibres of this kind must not be confounded with the very fine filaments seen in coagulated lymph, and which are produced apparently by the linear coalescence of molecules. (See Fig. 1.) The one are cell-fibres, and arranged when finished as fibro-cellular tissue, in fibres having cellular interspaces; the other are molecular fibres, and interwoven like felt in various directions, as seen in the clot of buffed and sizy blood, or in coagulated lymph exudation on the surface of a serous membrane. (See Fig. 1.) These fibres are, however, accompanied with numerous cells, each containing three to eight granules; and similar cells are found in reparative lymph, in which they abound. Hence named plastic cells by Dr. Hughes Bennett, they are the pyoid cells of Lebert, so named from their general resemblance to pus corpuscles. But, unlike them, neither water nor acetic acid much affect plastic cells. New capillary blood-vessels shoot through the connective tissue; they are formed also in coagulated lymph, and occasionally in blood-clot, as repa- rative materials. These vessels are produced by a highly interesting process of development, as described with that of Healing by Suppurative Granulation, in Contused and Lacerated Wounds. Eventually, the new tissue is fashioned off, so as outwardly to resemble the particular texture in the substance of which it is interposed; but this resemblance scarcely extends to their minute structure. Reproduction of the original texture is, in fact, a rare event. Skin, with its papillae and cuticle, muscle, tendon, artery, cartilage, and bone, in the first stage of fracture-union are severally represented by fibro-cellular tissue, more or less vascular; nerve is said to be repaired in like manner, and also by the formation of new nerve fibres, which running through the connective tissue, become con- tinuous with those in the nerve above and below, thus reinstating its continuity. The grey matter of nerve centres would not appear to be reproducible. This mode of union is less desirable than the immediate ; the forma- tion of lymph or exudation cells being a process so indefinitely separated from that of pus-cells, that union thereby is much more likely to pass into suppuration than any process in which no lymph is formed; then again, it is probably not so speedy in most cases; and finally, if accom- plished, it is not so close, a scar therefore always remaining by the organi- zation of the new intervening substance. (3) Suppurative granulation and cicatrization is that process by which all other than incised wounds are commonly healed. It will be described most advantageously in connexion with Contused and Lacerated Wounds. (4) Healing under a scab ranks higher, in respect of it3 result, than that by suppurative granulation. Open wounds, and superficial burns, INCISED WOUND. 247 may heal in either way. The cicatrix formed under a scab more nearly resembles the natural textures, and being also less contractile, is less dis- figuring. Yet the process of healing in this Avay is more liable to miscarry. Inflammation is apt to supervene, and discharge accumulating under the scab, the healing process is again and again delayed, or recommenced. No such impediment interrupts the progress of suppurative granulation, or the course of an open sore. The scab itself is formed o/ dried blood, lymph, or pus; but the precise nature of the reparative process underneath is concealed from our view. So far—observes Mr. Paget—as one can discern with the naked eye, the wounded surface forms only a thin layer of cuticle on itself; no granula- tions, no new fibro-cellular tissue, appear to be formed; the raw surface merely skins over, and it seems to do so uniformly, not by the progres- sive formation of cuticle from the circumference towards the centre, as is usual in open wounds. Healing by the " modelling process" is somewhat similar. It takes place under a scab or protective film. But that " natural growth" of textures proper to the part, by which it was said to be re-made or re- modelled, and which was thought to be the special and characteristic feature of the modelling process, is probably only the growth of granula- tions, without suppuration, because not exposed to the air. This mode of healing, like the last, is often witnessed in the wounds of animals. Macartney first described its characters, and I state them on his authority. " The pain arising from the injury soon ceases. No tumefaction ensues, separating the edges of the wound; and its surfaces are not only disposed to lie in contact, but even to approach each other so much, that they cannot be kept asunder by mechanic restraint; there is therefore no necessity for the effusion of lymph; and as there is no cavity to be filled up, granulations are not formed. The surfaces of the Avound, although they come into contact, do not unite by vessels shooting across; they are smooth, red, and moistened with a fluid, which is probably serum, and present the appearance of one of the natural mucous surfaces of the body. If any parts have been killed by the injury, they are detached by simply as much interstitial absorption as may be sufficient to set them free. The wound is finally healed by the same means which determine the shape of the natural parts of the body. It gradually diminishes in extent until obliterated; or it may be cicatrized before the surfaces are abolished, after which the same process of natural growth goes on until no part of the original wound remains. The cicatrix which succeeds the cure of injury by this modelling, or growing process, is small, pliant, free from callous adhesions to the parts underneath, and morbid sensations, that so often belong to cicatrices, which have for their bases deposits of lymph, or the new-formed structures, called granulation. " When the modelling process, or cure by natural growth, goes on perfectly, there is no inflammation in the part, and the patients are so entirely free from all uneasy sensations, that I have known instances of their being ignorant of the real site and extent of the injury until they had examined the part Avith their hand, or seen it in a looking- glass. " It might be anticipated, that as this mode of reparation bears so strong a resemblance to the natural formation and development of parts, it is the slowest mode ; but this is of little account when compared with 248 SPECIAL PATHOLOGY AND SURGERY. its great advantage in being unattended with pain, inflammation, and con- stitutional sympathy, and leaving behind it the best description of cicatrix. It constitutes the nearest approach, in the higher classes of animals, to the regenerative power exhibited by some of the inferior tribes."* The Prognosis of incised wound—as an adhering wound—is most favourable. But the breach of continuity may be maintained by various circumstances which prevent or impede coaptation of the parts. The weight and mobility of loose and pendulous parts, tend to prevent union, or to disunite them in the process of healing by primary adhesion. Muscular action, tending to displacement, will have the same effect, and to a greater degree, if co-operative. A deep and extensive flesh-Avound, say of the thigh, illustrates this concurrence of causes. Any foreign body— e.g., grit, or clot of blood—intervening between the surfaces, otherwise in apposition, will prevent complete union, and tend to induce suppuration with an open wound. These various conditions illustrate the Prognostic guidance of Persis- tent Causes. [P. p. 701.] But the surfaces of an incised wound are usually clean. Treatment.—To be effectual, in regard to this or any other lesion, surgical appliances must meet the requirements of the natural process of reparation, throughout its course ; of which the treatment will then be a continued reflection. The Indications are three :—(1) Arrest of haemorrhage ; (2) removal of foreign bodies ; (3) coaptation of the opposed surfaces. Hamorrhage.—Small vessels soon spontaneously cease to bleed ; their cut extremities retracting and contracting. Larger-sized arteries bleed per saltum, in jetting streams of florid red blood. Venous haemorrhage is distinguished by the even flow of purple or black blood. The treatment of haemorrhage will be described in connexion with Wounds of Arteries and Veins. But the arrest of haemorrhage, spontaneously, will be aided by exposure of the wound to cool air, or a stream of cold Avater squeezed from a sponge. Gentle pressure with the sponge on the cut surfaces will readily discover whether there be still any oozing from the bleeding points. Obviously, any foreign body, if present, should be at once removed. Not roughly, however. The same application of water, as for haemorrhage, Avill generally suffice to dislodge and carry away grit, &c, or the particles may be lightly brushed off with the wet sponge. Coaptation.—The coaptation of an incised wound might be postponed, until the wound has become glazed and adhesive. Then reparative material begins to exude. This indication as to time was always observed by Mr. Listbn, with regard to the amputation-wound of a limb, and all other large wounds. The deeper and more extensive the wound, the more advisable is it to wait this event; Avith one exception,—a deep muscular wound, which retracting and gaping, non-interference would allow the muscles to become agglutinated within their sheathing fasciae. But the general rule—applicable alike to small cuts, or to extensive and deep incisions, accidental or surgical, is this ;—haemorrhage having ceased or been arrested, and any foreign body, accidentally present, having been removed; the wound is now prepared to undergo the process of repa- ration. * Inflammation, pp. 53-4. INCISED WOUND. 249 (1) Coaptation signifies the adjustment of the apposed surfaces in even contact. This, however, implies a suitable position of the part, to relax any muscular action or tension. (2) Retentive Appliances.—Dressing.—The maintenance of coaptation during the process of adhesion, also implies the same attention to position; and some kind of retentive appliance; both being necessary to insure rest. In the selection of any such appliance ; the plastic nature of the healing process would indicate, that the less retentive it is, the better ; provided only it be sufficient to maintain easy apposition. The surgeon should always consider his mechanical dressings in this light; that he may the more exactly reduce them to co-operative conformity with the course of reparation. And by clearly understanding the proper management of a typical form of Injury, which occurs so frequently in Surgical Practice, as does an incised wound, and Avhich represents nine-tenths of surgical operations; he will be enabled to take a commanding view of his art. The appliances in question are designed to maintain the apposition of, either the lips, or the surfaces, of the wound. Plaster, sutures, or both, fulfil the one intention; a bandage, with or without light compresses, accomplish the other purpose. The plaster, commonly used, is the adhesive—diachylon—plaster. Isinglass plaster, introduced by Mr. Liston, is, however, preferable. It is equally adhesive, quite unirritating, and transparent, so that the progress of healing can be watched from day to day. If common adhesive plaster be used, the remark of Professor Gross is of some practical importance. It should be cut in the direction of its length, the texture in breadth being more yielding ; so that if cut in that direction, the plaster is apt to become loosened when heated by the skin. Any blood or dirt around the wound having been washed off, the surface is lightly wiped dry with a clean soft cloth. Blood remaining, it stiffens, tightens and irritates ; nor can it be removed subsequently without an unwarrantable degree of handling and rubbing. Thus also, any hair on the part, is better cut off in the first instance. Strips of plaster, of length and breadth suitable to the size of the wound, are then applied; and most advantageously, by placing the first strip over the centre, and another on either side alternately, leaving intervals betAveen them wherever the edges of the wound lie in even and easy apposition. Any oozing is thus allowed to escape, the more so from a deep wound. Sutures are made of silk-twist; or metallic wire, of various kinds; gold, silver, iron, or lead. They are apt to induce inflammation and ulceration of the skin around each, as a centre. Silver-wire is, perhaps, less irritating than silk, which acts as a seton. A number of such sutures are, in effect, so many little setons, along the margin of a wound. The apparently greater tolerance of silver sutures, is witnessed after the operation of joint-excisions. Fine telegraph wire has been introduced into surgical practice by Mr. Clover. It consists of a fine copper-thread, coated with gutta-percha. This is soft, flexible, tough, and perfectly unirritating; it admits, therefore, of ready introduction and knotting as a suture, and it may be left in the tissues for ten or fourteen days, with- out inducing any suppuration or inflammation along its track. Sutures, of some kind, are necessary alone, or as adjuncts to strips of plaster, Avhenever the Avounded part is liable to be disturbed; whether by muscular action, its OAvn Aveight, or looseness. Such parts are the lips, tongue, soft palate, cheeks, nose, eyelids, ears; breasts, abdominal walls, 250 SPECIAL PATHOLOGY AND SURGERY. Fig. 31. bowels, scrotum, and the integuments around joints. When used, sutures are applied before the retentive strips of plaster; and only to bring the margins of the wound together, here and there, forming the "interrupted" suture. (Fig. 31.) Commencing in the centre of the wound, in order to judge of the even ad- justment of the rest of its extent, the first suture is inserted by means of a curved needle, armed with silk or wire. Then another is placed alternately on either side, and so on, from point to point; but only Avhere necessary to secure apposition. Fig. 32. Fig. 33. Fig. 34. If silk be used, each suture is tied with a reef-knot; if wire-suture be used, a twist or two will secure it. In either case the ends are then snipped off short. As few sutures only, as may be requisite, should be inserted ; for, besides their irritating character, coaptation can be efficiently main- tained in the intervals between them by strips of plaster. (Fig. 32.) Other forms of suture are employed in special kinds of incised wounds. The " twisted " suture is a waxed thread, twisted or coiled into a figure of 8 shape around a fine needle, previously transfixed through the lips of a wound in apposition. (Fig. 33.) It is most serviceable for wounds of the lips, as in the operation for hare-lip, and for wounds of the abdominal walls. The " quilled " suture consists of a number of interrupted su- tures, secured, not across the lips of the wound, but, on either side, to a quill, piece of bougie or other small cylinder, placed parallel about half an inch from the margins of the wound. (Fig. 34.) Textures below the surface are thus approximated and steadily held together; an advantage in respect to a deep wound, as well as in any moveable part. Rup- tured perinaeum is thus secured. The " uninter- rupted " suture, or Glover's stitch, is seldom used, excepting for wounds of the intestine, which are INCISED WOUND. 251 stitched close so as, if possible, to prevent the escape of faecal matter. The " button" suture of Bozeman, the "clamp," and the " serrefine," of M. Vidal, may be here mentioned. A bandage or roller, and compresses or light pads of lint, may be required to maintain the surfaces of a wound in contact. This, more especially, if the parts are muscular and liable to retraction, or bulky and apt to fall asunder. Deep or excavated wounds, therefore, mostly need this extra restraint or support. But it should be applied evenly, and only with sufficient pressure to invite adhesion, by preventing dis- placement and any oozing haemorrhage. Amputation-wounds well illus- trate the circumstances alluded to. Muscular retraction and weight of the flaps, thence recurring displacement and oozing haemorrhage, are overcome and obviated, by the additional retention of compresses and a bandage applied with even and moderate pressure. The line of incision, visible between the strips of plaster, needs only the protection of a piece of wet lint, as "water-dressing," covered with oil-silk to retard evaporation; and which may be occasionally moistened without removing it or otherwise disturbing the healing process. Col- lodion is sometimes used for the purpose of temporarily sealing the lips of an incised wound. Applied with a camel's-hair brush ; it should be used quickly, and in such quantity that one application of the brush may suffice; for collodion is very adhesive, dries almost immediately, and contracts. Antiseptic-Dressings.—Disinfection and Deodorization have, of late years, attracted much attention, more particularly in this country; and especially in the treatment or dressing of Wounds, whether ■occasioned by accident or by surgical operation. These terms, disinfection and deodorization, are not at all necessarily synonymous. Disinfection re- presents the neutralization or destruction of the infectious property, whatever that may be, in the atmosphere, or in any liquid, or solid substance, as an article of clothing—whereby a disease, itself infectious, is communicated and propagated; Deodorization signifies only the neu- tralization of an odoriferous property, and possibly, simply by masking it by some more powerful and penetrating odour. Probably, disinfection is far more frequently attended with deodorization, than the latter implies the former. Thus, solutions of carbolic acid, chlorine, and chloride of zinc, are Disinfectants; whereas, the aroma wafted from burning spices, or the fragrant spices of the East, employed in times gone by, would sweeten rather than purify the sick chamber; like the camphor-bag in domestic use, or the time-honoured rue strewed about the dock of our criminal courts—all such agents more often delude the sense only—they are Deodorizers. In relation to Infectious Fevers—diseases which equally concern the Surgeon and Physician, the prevention of Infection and its propagation, is fully considered in my other work. [P. Ch. viii.] Disinfection in relation to the treatment of Wounds—accidental or surgical, may be termed Antiseptic; the object being to prevent the putrefaction of any blood or liquor sanguinis extravasated, or of pus formed subsequently—and it would seem to also control the formation of the latter fluid. Thence, primary union of the wound is induced, and the liability to purulent infection of the blood—Pyaemia, or by de- composing animal matter, septic matter, producing Septaemia, is prevented; the further Hability of any propagation of infection being necessarily 252 SPECIAL PATHOLOGY AND SURGERY. excluded, as the wound remains healthy, and heals with little or no sup- puration. The principle of antiseptic-treatment is twofold :— Firstly. By the exclusion of air, as the infecting agent, from the wound. Secondly. By the interposition of some positively disinfecting, or antiseptic dressing, in the form of a close covering to the wound. Pro- fessor Lister of Edinburgh—who has mainly originated antiseptic-treat- ment—enlarges this aspect of the principle, thus;—" an antiseptic to exclude putrefaction, with a protective to exclude the antiseptic, will by their joint action keep the wound free from abnormal stimulus."* This principle may he fulfilled as follows :— (1) Exclusion of air from a wound may be effected by simple water- dressing, as already described ; care being taken to apply the dressing so as to form a close covering, and which is enveloped in oiled-silk. Or, the air may be withdrawn by an exhausting receiver, as has been tried in France. (2) Antiseptic-dressings of various kinds have been used; and as a process of treatment, comprising many details, apparently essential to its success as a specific method, this has been named by Professor Lister, the " Antiseptic system of Treatment." (a) The " protective " should possess several properties ; it should be a material impervious to carbolic acid, and unstimulating in its own sub- stance ; at the same time, it must be insoluble in discharges, and suf- ficiently supple to apply itself readily to the part. Various materials have been tried and discarded ; as a metallic plate, itself impervious, but when made of block tin, it was too rigid, and tin-foil soon Avears into holes. Gutta-percha soon transmits carbolic acid. The " protective " Lister now uses, is oiled silk; prepared by having a thin coating, brushed over it, of a mixture consisting of one part of dextrine, two parts of powdered starch, and sixteen parts of cold watery solution of carbolic acid—1 to 20. (b) Antiseptic " lac-plaster " is laid evenly over the protective and ex- tending freely beyond the wound ; and over both, the part is enveloped with a cloth, to absorb any discharge which may ooze from beneath the margin of the impermeable plaster, the cloth being secured in position by a roller-bandage. The plaster now used is incorporated with a soft cloth, instead of being spread upon starched calico.y It is thus made more flexible and durable, but very thin ; so that a double layer may be advisable, to double the store of acid in the application, when much dis- charge is anticipated, or when the dressing is not to be removed for some time. " The carbolic oil," and "carbolic paste or putty," formerly used and advocated by Mr. Lister, he now seems to have almost abandoned. Recently, however, to complete the antiseptic appliances which may be requisite in the treatment of wounds; he has devised " antiseptic liga- tures " of prepared catgut, for securing blood-vessels, and " antiseptic sutures," for retaining the lips and surfaces of a wound in contact. Previously, to applying the solid antiseptic dressing, above described, the wound is well syringed out with " carbolic solution or lotion," as strong as it can be made,—one part of the crystals to twenty of water. The * A Case of Compound Dislocation, &c, illustrating the Antiseptic System of Treatment. 1870. t This plaster, in its best form, may be obtained from the Old Apothecaries' Company, Virginia Square, Glasgow. INCISED WOUND. 253 transient irritant property of this strong solution, is said to be far less objectionable than the abiding influence of the more acrid products of putrefaction ; even although the solution be thrown into the interior of a large joint, as in the dressing of a compound dislocation of the ankle-joint. A weaker lotion, one to forty, will suffice, in dressing a recent, and surgical, wound. The skin around a wound is well washed with the lotion. Then, the protective, lac-plaster, outer cloth and bandage, are severally applied. Reapplication of the dressing may be required, or advisable, occa- sionally ; in the intervals, the bandage and cloth may be daily moistened Avith carbolic solution, strong or Aveak,—one to eighty, to renew a supply of the antiseptic to the lac beneath. Great care must be taken in removing the antiseptic dressing, not to admit air into the wound, or any regurgi- tation of discharge. Hence two precautions; in removing the cloth, the plaster should be held down over the wound, so as not to be drawn up with it, at any part where they may have become adherent by dried dis- charge ; then, in raising the plaster, the nozzle of a syringe is inserted beneath its margin, and a stream of carbolic solution is thrown over the Avound, until a piece of calico soaked with the same lotion, has been placed upon it, as a temporary security, pending the reapplication of the plaster. " These details, while essential to success, are, happily, easy of execution." Theory of the Antiseptic Treatment.—To form an impartial judgment respecting the efficacy of "antiseptics," it is necessary, as in all other aspects of surgery, to draw a sharp line of distinction between observed facts, and their supposed explanation or interpretation. The non-recog- nition of this obviously important distinction has influenced both favour- ably and unfavourably, the practice of antisepticism. To prevent, if possible, the putrefaction of animal matter, whether as blood or discharge, in contact with wounds, is known to be most important, pathologically, as an observed fact; and that carbolic acid has some such influence, is another observed fact. But, how it operates is doubtful. Opinions are divided, though not equally. Omitting the small section of disbelievers in antiseptic treatment, the Profession generally, as believers, are divided respecting its modus operandi. The chemical theorists attribute the putrefaction observed, to the decomposition induced by the oxygen of the air, a process of oxi- dation. The ^erm-theorists attribute the putrefaction observed, to the pro- duction of living organisms developed from germs or ova floating in the atmosphere, as constituents of its dust; and not as the result of " spon- taneous or equivocal generation," in the putrifying animal matter. The balance of evidence would seem to be in favour of the latter or germ-theory. The observations of Cagniard Latour, 1836, in the dis- covery of the yeast plant, followed by those of Schwann of Berlin, in the folloAving year, and the subsequent discovery of minute, jointed, living bodies,—vibrios in putrid matter, supplied the basis of the germ-theory(; while the well-known power of the atmosphere to carry and disseminate seeds or dust, completed the theory. The researches of Pasteur seem to have brought it to actual demonstration. Hence, antiseptic treatment would consist, in excluding the atmosphere from wounds, and in interposing some agent Avhich shall destroy the germs in their introduction by any 254 SPECIAL PATHOLOGY AND SURGERY. exposure to the air. Has carbolic acid, or other so-called antiseptics, any such effect ? The question is still sub-judice. Results.—Comparing the aggregate results of amputations, in the Glasgow Royal Infirmary, Professor Lister finds the mortality to have been:—Before the antiseptic period, 16 deaths in 35 cases, or 1 death in every 24; cases; whereas, during the antiseptic period, it was, 6 deaths in 40 cases, or 1 death in every 6f cases. This is certainly a greatly diminished mortality, and its significance is more notable from the relative death-rate of amputations in the upper limb; where generally, neither the injuries nor the operations involve much loss of blood or shock to the system, so that if death occurs, it is commonly the result of the wound assuming an unhealthy character. There were 12 amputations in the upper limb, in each of the periods referred to. Of the 12 cases before the antiseptic period, 6 died; but of the 12 during that period, only 1 died, and 11 recovered. The deaths were caused, principally, by pyaemia, erysipelas, and hospital gangrene. Thence, it would appear, may be inferred " the effects of the antiseptic system of treatment upon the salubrity of a Surgical Hospital."* After-dressing.—An incised wound should not be disturbed unneces- sarily during the process of adhesion. Inflammation can scarcely be said to supervene. In the first instance, it starts this reparative process. Attended with a slight pouting and redness of the lips of the wound; this salutary degree of inflammation should not be repressed ; and, being transient, inflammatory fever is not excited, from first to last, if the wound, however extensive and deep, continues to heal by adhesion. The consti- tution remains calm and impassive throughout the process, taking little or no notice of the local reparation effected by the part itself. Consequently, no antiphlogistic treatment, topical or general, becomes necessary; but the lightest dressings to maintain apposition, and the gentlest handling in applying them, are still sufficient. The first dressing is not unfrequently the only one nature requires; the wound healing in two or three days, possibly in twenty-four hours. But union is not then secure, nor much before the end of a week in small wounds, and a fortnight in larger incisions. Therefore, during even the shortest period requisite for sound union, the dressings must be changed occasionally; their reapplication having reference always to some obvious and important purpose. Cleanliness, rather than readjust- ment of the wound, is the guiding maxim for interference. The strip of lint is to be withdrawn wet, not to disturb the lips of the wound, as yet tenderly united. The strips of plaster, also moistened to facilitate their removal, are withdrawn by both ends together gently towards the line of incision, not to undo the work of nature; and each strip is replaced by a fresh one before the next is removed, not to leave any part unsupported. The removal of sutures, if any, will be guided by the progress of adhe- sion, or by the accidental supervention of inflammation. Within the first twenty-four hours, some, at least become useless, or worse,—irritating. These sutures should be picked out, wherever, from point to point, union appears safe, or the blush of inflammation is conspicuous. Otherwise they will ulcerate their way through, and so peril the healing process. In the event of considerable swelling and tension, the lips of the wound having a * I have endeavoured to gather the foregoing description of this treatment, and its results, from several monographs which Mr. Lister kindly forwarded to me for this purpose. WOUNDS OF ARTERIES AND VEINS. 255 tightly puckered appearance at the point of each suture, and a pouting or protruding condition in their intervals; all the sutures must be with- drawn forthwith. If thus released, the lips do not adhere, the surfaces may do so, partially or entirely. The removal of any ligature or ligatures, is, like their application, not necessarily part of the treatment of an incised wound ; and will be con- sidered under Wounds of Arteries. The bandage, if any, and the compresses, if any, are no longer needed when union is sufficiently firm not to risk straining the parts, by the loss of these surface-supports. Generally, the first few days will suffice. Any swelling, hoAvever, as in amputation-wounds, may yet require the partial support of a turn or two of the bandage, until tension has subsided. Thus, one by one, the appliances of Surgery are withdrawn ; one by one, these artificial props are removed; until at length, and ere long, in most cases, nature is able to consolidate the union, without further assis- tance. Such then is, what I would term, the " conservative " treatment of in- cised wounds ; an example, from first to last, utterly opposed to meddle- some Surgery. Wounds of Arteries and Veins. These Lesions are conveniently taken next in order. Wounds of Arteries.—Structural conditions.—A wound of an artery, like that of any other texture, may be incised, or lacerated; either of which lesions may be partial or complete. Incision, partially extending ]7IG. 35. through an artery, and practi- cally equivalent to a punctured wound, varies in direction ; being longitudinal, oblique, or trans- verse, and these are important practical distinctions (Fig. 35); so also is the variation in size of the aperture, which may be of any circumferential extent, short of complete division of the vessel. Laceration, partially extending through an artery, is limited to one or more of its three coats; the external, and more or less of the middle coats, may be torn through, leaving only the thin inner one entire ; or, the two inner coats are severed, leaving only the thick external, cellular coat untorn. This latter condition of laceration is effected by the surgical application of a ligature. Lastly, all three coats are torn through, if the laceration be complete; but the external-cellular coat and cellular sheath, being tougher than the two inner coats, are drawn out from off them, Avhich also retract; thus leaving a canal of loose cellular tissue. The Signs of any such wound of an artery, are haemorrhage, the blood having a florid red colour, and jetting out from the vessel, per saltum, with each beat of the heart; not escaping in a continuous stream of purple or black blood. The force, and in a degree, the rapidity of these jets are regulated by the size of the artery, or of the aperture in it, by its proximity to the heart, and by the heart's action; also by the presence or absence of certain conditions which retard or favour the free flow of blood through the vessel. Thus, pressure on ^the proximal portion of 256 SPECIAL PATHOLOGY AND SURGERY. artery retards, while a dependent position favours the haemorrhage. The blood coming from the distal portion of vessel is dark, and runs in a trickling stream, excepting from certain arteries, as the palmar and plantar arches, which when wounded, jet arterial blood from either extremity of the vessel. Causes, and effects of Wounds of Arteries.—An artery may be incised or cut with a sharp instrument, punctured Avith a pointed one, contused or lacerated by a blunt one, or wounded by force of a bruising or wrench- ing kind. The operation of any such lesion locally, is to produce aneurism, if the blood be imprisoned in the textures; constituting traumatic aneurism, —diffused, or eventually circumscribed. Its formation will be specially described in connexion with aneurism. Constitutionally regarded; whether arterial haemorrhage takes place externally, or internally, as into one of the great cavities of the body, its effects are manifested by syncope or fainting, more or less complete. And this may occur either by failure of the heart's action, cardiac syncope, and thence of the circulation; or as loss of consciousness—cerebral syncope ; or both modes of syncope may be produced, with a fatal termination, if the haemorrhage be suffi- ciently prolonged. These constitutional effects and the probability of death resulting, are proportionate to the quantity of blood lost; not necessarily by its escape from the body, but even Avhen lost to the body as blood in circulation. Providentially, hoAvever, the imminent peril of continued haemorrhage is lessened by cardiac syncope; suspension of the circulation, tends to arrest the escape of blood from the artery, and by thus favouring the formation of an occluding clot, it tends also to arrest the haemorrhage. Reparation.—If the vessel be healthy, the lesion is uniformly disposed to heal by coagulation of the blood and the formation of a clot or clots so placed as to arrest the haemorrhage; a temporary provision, followed by primary adhesion, or, possibly, adhesive inflammation, whereby the vessel is permanently secured or obstructed. But this process of coagula- tion and adhesion is modified chiefly according to the structural kind of wound—incised or lacerated, either of which may also be a partial or complete division of the artery. Then, again, the direction of the wound more particularly modifies the process of healing. 1. An incised and partial division of an artery is the simplest instance. (See Fig. 35.) If the direction of the cut be longitudinal or oblique, it will close more readily than a transverse incision, the edges of which gape and do not fall into apposition. The elasticity of arterial tissue longitu- dinally makes all the difference, and in favour of that direction, aided also, in this case, by the circular contractility of the artery. The line of incision remains closed ; blood escaping coagulates betwixt the vessel and its sheath, forming a compress, assisted by any corresponding coagulum which may have formed outside the sheath. The relative positions of the apertures in the artery and its sheath are displaced somewhat by the for- mation of the intervening portion of clot-compress, thus further tending to arrest haemorrhage. The homogeneous fibrils, interspersed with many- nucleated corpuscles, of which coagulated fibrine consists, are repre- sented in Fig. 1, p. 42. Associated with blood-corpuscles, it forms the clot. But this clot-compress is a temporary provision only. Adhesion soon follows in the line of incision, the edges being in contact. A transverse cut, partly through the circumference of an artery, opens, the WOUNDS OF ARTERIES. 257 vessel contracting longitudinally by virtue of its elasticity. Adhesion cannot ensue. The aperture is closed by the effusion and organization of lymph within the artery, which thus becomes impervious and obliterated. Lost, however, for ever* as a blood-conveying tube, haemorrhage of fatal character is arrested. Nature is still victorious. The size of the vessel will someAvhat affect the issue, Avhich is otherAvise in favour of a longitu- dinal incision. An artery, like the temporal, with a longitudinal slit, heals without obliteration. An artery of larger calibre, and similarly wounded, becomes impervious and obliterated. And the ultimate success of Nature's effort is apt to be marred, even when the wounded vessel remains pervious; for the internal and middle coats not adhering firmly, this defect predisposes to aneurism. 2. Complete division of an artery by incision is healed by a modifica- tion of the same process—clot formation, but not as a compress, being the temporary provision, lymph effusion permanently plugging up the \-essel. Immediately after its division the artery retracts by its elasticity, longitu- dinally, into its sheath, which thus projects loosely; the mouth of the vessel contracts, even to a pin-hole opening, by its muscular contractility circularly. The retracted portion thus contracted has a conical shape, like that of a Florence oil-flask or French claret-bottle. (Fig. 36.) Contractility may be sufficient to close the vessel and prevent further haemorrhage. In this way small arterial branches spontaneously cease to bleed in an open wound exposed to the air, or the action of cold water ; but the artery having retracted, coagulation is induced within the loosely projecting fila- mentous sheath, which entangles the blood as it flows; and this event may be aided by cessation of the stream, owing to failure of the heart's action—cardiac Fig. 36. syncope—another resource of Nature for the temporary arrest of haemorrhage. Coa- gulation proceeds concentrically. The clot, at first pervious and transmitting a small central stream of blood, soon forms a solid mass, which, still enlarging, passes up the bore of the artery for a short distance in the shape of a small cone. This portion— internal coagulum or bouchon—and that in the sheath—external coagulum or couvercle —together form a clot, in shape like a glass stopper fitted into a decanter, to which the Avhole is compared by Professor Gross. The shape of Nature's product is not quite so finished off, for a small portion of the clot is insinuated between the sheath and artery beyond the point of retraction, thereby com- pressing the arterial aperture, while a still larger portion of an irregular shape projects beyond the aperture of the sheath. The whole clot is, how- ever, continuous, and Avith these little offsets still bears the resemblance suggested. The permanent closure of the vessel is effected by the effusion of plastic lymph. Like coagulated fibrine, its organization consists, essentially, of fibrils; but those of plastic lymph result from the elonga- tion and attenuation of cells into fibres, in various stages of development. (Fig. 1, p. 42). Corresponding in situation to the clot—i.e., at the aper- ture, around it slightly, and extending into the vessel, the lymph in- s 258 SPECIAL PATHOLOGl AJND SUKtfER'i. tervenes between it and the clot, which it gradually replaces. During this change the clot varies in appearance, being partly lymph, and partly ordinary coagulum. The lower end of a divided artery is closed-up much in the same way. According to Guthrie's observations it retracts and contracts less than the cardiac end ; and the internal coagulum is altogether absent, or very imperfectly formed in many instances. 3. A lacerated wound of an artery, if partial, may extend through the external and middle coats, leaving only a thin undivided inner membrane, which still continues the channel of communication. Haemor- rhage is imminent. Or the laceration may extend through the inner and middle coats, leaving the outer cellular coat entire. Haemorrhage threatens, or gangrene may superArene. But if the two inner coats be cut rather than torn, reparation generally takes place and secures the vessel. Such is the kind of injury purposely inflicted by the Surgical application of a ligature, which leaves the external coat undivided ; and although itself noxious, as a foreign body in the very pathway of repara- tion, the artery becomes sealed with plastic lymph, plugged up also with coagulum, and obliterated. The details of this process, thus artificially induced by Surgical interference, will be described in connexion with the treatment of haemorrhage. 4. Complete laceration of an artery—all the coats being torn through—heals without haemorrhage or scarcely any. The process is the same as that Avhich takes place after division of an artery by incision. But the cellular sheath and outer cellular coat are drawn off the two inner coats, which retract. Con- sequently the clot that forms in the projecting portion of loose sheath is larger than when the vessel is simply cut across; presenting a bulb-shaped extremity which may extend to half an inch or an inch in length. This appearance is Avell shown in Fig. 37, which represents a popliteal artery and vein in a remarkable case, both vessels having been ruptured by a violent twist of the knee-joint. Gangrene of the leg ensued, for which I amputated above the knee; with, how- ever, a fatal result. Treatment.—Arrest of haemorrhage, is the first indication of treatment. Small arterial vessels spon- taneously cease to bleed, almost immediately; the process of reparation, as appropriate to the injury, at once commencing, and even its preliminary stage proving sufficient to arrest haemorrhage. Thus, if the vessels be divided entirely across—complete incision—as in most wounds, their cut extremities retracting and contracting soon offer ade- quate resistance to the escape of blood. This natural provision will be insured by exposure of the Avound to cool air. or a stream of cold water squeezed from a sponge. Gentle pressure with the sponge will readily discover whether there be still any oozing from the bleeding points. Larger-sized arteries bleed in jetting streams of florid blood, and the resources of Surgical treatment are forthwith necessary to meet such haemorrhage. These are successful so far as they represent, by imitation, one or other of the natural modes of arresting haemorrhage. WOUNDS OF ARTERIES. 259 1. Compression—mediate, as it is sometimes termed, when not directly applied to the bleeding vessel—may be effected either by the finger or a tourniquet, applied over the parent artery, at the most eligible spot betwixt the wound and the heart. Pressure thus applied is only a temporary resource. Immediate compression is effected by pressure directly applied to the bleeding vessels. A compress and bandage, applied firmly, but not with unnecessary tightness, Avill thus prove sufficient. This mode of compression may be regarded as representing the clot compress of nature. 2. Ligature.—The ligature is a Surgical appliance in imitation of a lacerated wound, partially extending through an artery—i.e., through its two inner coats, Avhich are thin and fragile, leaving the thicker and tougher outer coat and cellular sheath untorn. The effectual operation of this appliance is—compression of the vessel to induce coagulation of the blood stagnant above and below the ligature, and the effusion of plastic lymph, from the divided coats, to permanently occlude the vessel in both directions; sloughing of the included ring of outer coat and cellular sheath being rendered necessary to detach the ligature. The details of this reparative process, thus induced artificially, are these. The included portion of external cellular coat and sheath having undergone continued compression, sloughs, and is detached with the thread, in a period varying from tAventy-four hours or so to about three or four weeks, chiefly according to the size of artery. Haemorrhage Avould then be inevitable ; but, pending the detachment of this slough- ring, effusion of plastic lymph, from the vasa vasorum, takes place, Avhereby the two inner coats become adherent across the area of the vessel, just above and below the ligature. At these points they curl inwards when divided, and, converging, meet together. This condition was Avell seen in a femoral artery, and vein (Fig. 38), Avhich I examined five days only after it had been ligatured when the thigh Avas amputated. A process of organiza- tion, therefore, above and below the ligature, accompanies the destruction and detachment of the ring of external coat embraced by the thread. Thus the artery is securely sealed. Accessory, but incidental only, to the prevention of hae- morrhage, are certain changes Avhereby either portion of the artery contiguous to the ligature is obliterated. The vessel having ceased to convey blood when the ligature Avas applied; the blood stagnant, above and beloAA", to the nearest collateral branch, has gradually under- gone coagulation in the shape of two conical clots, the bases of Avhich accurately plug the artery on either side of the thread. The apex of the clot on the cardiac side tails off, usually opposite the first collateral branch above, through Avhich the stream of blood, now diA^erted from its course, is carried off from the main. The distal clot is ahvays less defined. At first either clot having the appearance of ordinary coagulum, subsequently it becomes mottled with paler spots, and its sub- stance porous, and ultimately acquires a buff colour, firm consistence, 200 SPECIAL PATHOLOGY AND SCRt.EuT. and fibrous texture. Blood-vessels, proceeding from the lymph imme- diately above and below the ligature, shoot into the base of either clot, and gradually extend towards its apex. Finally, these organized fibrous clots are incorporated with the lymph adjoining, which has acquired a similar structure ; the coats of the unused portions of artery degene- rating also assume a fibrous character, and the whole is converted into a small, firm, impervious, fibrous cord, extending usually to the first collateral branch above and below. Nature having safely severed the artery—under compression by the ligature—and securely sealed either end, has now obliterated the portions useless as a blood-conveying tube. An artery of any notable size is most effectually and permanently secured by ligature. Appropriate, therefore, for the arrest of haemorrhage which would otherwise be persistent or recurring and perilous, the liga- ture is applicable also whatever may be the kind of wound in the vessel, whether incised or lacerated—its extent, partial or complete—and its direction, with reference to the elasticity and contractility of the vessel. The objections to ligature are ; the production of a slough or sloughs of arterial texture, according to the number of vessels ligatured; the intro- duction of a foreign body, or as many foreign bodies, into the flesh- wound—a condition proportionately antagonistic to the process of healing by primary adhesion ; and, that suppuration consequently, and the sloughs, are provocative of pyaemia. The efficacy of ligature in the treatment of haemorrhage from wounds of arteries, of flesh-wounds, and in relation to pyaemia, is to be estimated by all these considerations ; and thence the value of this method of treatment as compared with that of " acupressure," proposed to supersede it. Certain particulars are of great moment in the application of a liga- ture ; the observance of which, a due knowledge of the process thus induced for the arrest of haemorrhage, can alone insure. It is in this light that I specially here advert to them. But they have reference also to the value of ligature, as a method of treatment; for they determine the probability of haemorrhage recurring or supervening, and also of the healing of a flesh-wound by primary adhesion when an artery or arteries are thus secured. The practical particulars having this twofold significance are these :—A ligature should be applied to cut through the tAvo inner coats of the artery, leaving only the outer more resisting cellular coat and sheath. Hence the ligature must be a small, round, and strong thread—fine silk twist waxed being found to answer best. Ap- plied with sufficient tightness for this purpose, and to induce sloughing of the outer coat by strangulating compression. Ap- plied transversely across the dia- meter of the vessel, and tied with a reef-knot (Fig. 39) ; other- wise the ligature shifting its posi- tion and loosening, haemorrhage recurs or supervenes when adhesion is not yet sufficiently advanced to WOUNDS OF ARTERIES. 261 safely seal the vessel. Applied so as not to include any extraneous texture —a bit of muscle, a vein, or nerve; for then the tAvofold effect on the artery enclosed may not be produced, or sloughing may proceed more speedily in the extraneous texture than in the arterial coat, the ligature become loosened, and haemorrhage supervene. Inclusion of a nerve- filament causes also great pain at the time, and for a considerable period in some cases. An imbedded artery may be inaccessible without in- cluding some other texture. In the most inaccessible situations—as when, by amputation, the anterior, tibial artery is divided at its origin and deep in the muscles between the heads of the tibia and fibula— it is absolutely necessary to " dip " for an artery so placed. A curved needle armed with a ligature is thus carried round the vessel, and the thread tied as usual, but including as small a quantity of extraneous texture as possible. On the other hand, the ligature should not be applied to any projecting portion of the artery; the vessel being there denuded of its own nutrient vessels (vasa vasorum), plastic lymph is not effused, and Avhen the slough-ring separates, haemorrhage is inevitable. Regarded as a foreign body, antagonistic to healing by primary adhesion, one end of the ligature is usually cut off close to the knot on the artery, leaving only the other end to command the noose, thus reducing the quantity of foreign body in the wound by one half. The ligature or liga- tures may be brought to one or other angle of the wound, and there fixed by a small piece of plaster, thus also limiting any defective adhesion to the narrow track occupied by the thread or threads. Practically, it is found they do not much interrupt the process of healing or delay the issue. Duly observing all these suggestions of pathology, the constructive part of the process—adhesion—will generally accompany the destructive —sloughing—with even progress, and the issue of both will be contem- poraneous ; permanent closure of the vessel accompanying the separation of a ring of slough with the ligature. The security of the vessel is safely ascertained by gently twirling the thread between the thumb and finger. A yielding sensation shows that Nature has done her work, and that the ligature detached can be withdrawn without the risk of haemorrhage. This, however, cannot be expected, nor should the experiment be tried before sufficient time has elapsed—the period varying from tAventy-four hours to as many days or more, chiefly according to the size of the artery. 3. Acupressure has been proposed by Sir James Simpson as a sub- stitute for ligature. It is essentially the " temporary metallic compression" of an artery,* and it may be accomplished in either of three Avays:—(1) By passing a long needle twice through the flaps or sides of a Avound, so as to cross OA^er and compress the mouth of the bleeding vessel or its tube; just as in fastening a flower in the lapel of our coat we cross over and com- press the stalk with the pin Avhich fixes it, and therefore pass the pin twice through the lapel. In this method a long needle is introduced from the cutaneous surface, and its extremities left out externally. In both the other methods a common seAving-needle, threaded with iron-wire, is used. The needle is introduced on the raAV surface of the wound, and is therefore placed altogether internally or betAveen the lips of the Avound. The wire is only for the purpose of withdraAving the needle when no longer required. (2) In one of the methods referred to, the needle is dipped down into the * Acupressure. 1864. 262 SPECIAL PATHOLOGY AND SURGERY. textures a little to one side of the vessel, then raised up and bridged over the artery, and finally dipped down again into the textures on the other side. This method, therefore, is the same as the first, but that the needle is applied altogether on the raw surface of the wound and.over the artery, which it compresses. (3) The third method consists in passing a needle Fig. 40.* under the vessel, transfixing the textures once. A loop of wire is passed over the point, and fastened round the eye end by a single tAvist, thus compressing the artery and some surrounding tissue between the needle and the wire. This method Sir James Simpson believes to be the one which will probably be most frequently practised (Fig. 40). In one form or other acupressure is said to be superior to ligature, both with regard to the improbability of secondary hemorrhage—the pro- bability of healing by adhesion, and the improbability of purulent, or other septic infection of the blood, pyamia. (1) Respecting hamorrhage after amputations, in eleven cases of acu- pressure only one was followed by secondary haemorrhage; whereas in eleven cases of ligature, four of secondary haemorrhage occurred, of which two were fatal. Such were the comparative results after amputations at the Carlisle Hospital (Hamilton's Report). In other Avords, in that insti- tution, secondary haemorrhage from ligature and from acupressure Avas as four to one in eleven cases. Other favourable results might be added. The most recent report is that of Professor Pirrie,"(- who, Avith Dr. Keith and Dr. Fiddes, have more especially practised and advocated this mode of arresting arterial haemorrhage. The former thus enumerates his " ex- perience in important cases, of which records have been kept. Eleven cases of amputation of thigh, four of amputation of leg, tAvo of amputation of arm at the upper part of the surgical neck of the humerus, one of amputation at ankle-joint, one of Chopart's amputation, two of amputation of the whole of great toe, twelve of excision of mamma, six of excision of elbow-joint, one of excision of knee-joint, one of excision of an erectile * Occlusion of Arteries ; the femoral arteries, after Acupressure, and Ligature—in double amputation—each twenty-four hours. (Author.) T British Medical Journal : Annual Meeting of the Association, Dublin, 1867. See also Acupressure. WOUNDS OF ARTERIES. 263 tumour, one of excision of tumour on chest, one of excision of tumour on thigh (wound eight inches long), one of excision of head of fibula, three of excision of testicle, one of haemorrhage from sloughing of hand, one of wound of hand, one of wound of upper part of forearm Avith great haemorrhage, one of wound of radial artery, and one of Avound of hand attended Avith great haemorrhage—in all fifty-one cases, in Avhich I have acupressed 185 vessels." But experience has not yet sufficiently accumulated to determine the relative value of these two kinds of treatment with reference to the impro- bability of haemorrhage supervening. Nor had pathology hitherto deter- mined this question. " We want," acknowledged Sir James Simpson, " a series of proper experiments and observations as to the actual pathological mechanism by Avhich acupressure occludes the mouths and tubes of arteries, before Ave can attain fixed ideas as to its progress and completion." Ac- cordingly, in the year 18(37, I endeavoured to supply this desideratum by post-mortem examination of the process of occlusion in arteries, after acu- pressure, and its relation to the treatment of surgical haemorrhage, com- pared also Avith ligature and torsion. The results of my observations were communicated in a Paper to the Clinical Society, in 1871. Pre- viously, the observations of Mr, H. Lee, and Mr. J. W. West, respectively, relative to acupressure were brought before the same Society. The prac tical object of my inquiry was, by a due knowledge of the process of occlusion, to determine the proper period for the safe withdrawal of the needle from a main artery, as the femoral, and the various periods in respect to different sized arteries; rather than having recourse to the peri- lous mode of investigation, by tentative ex- perience on living patients, in the treatment of haemorrhage by acupressure. Thus would be determined the liability of secondary haemorrhage occurring in this mode of treat- ment. Occlusion, after acupressure, consists, essentially, in the formation of a conical clot, adjoining the transverse line of acu- pressure, or needle; this clot increases in length, extending up probably to the first collateral branch of artery, and it increases also in calibre, so as to completely occupy the bore of the vessel at, and for some dis- tance adjoining the line of acupressure. Thus the artery is plugged (Fig. 41). This clot soon undergoes structural changes ; be- coming fibrinous in its distal portion, partly fibrinous, eventually perhaps entirely so, in its proximal portion, and there adherent to the interior of the artery. Further changes, I have not yet traced. But, it Avould seem highly probable that the occluded portion of * Occlusion of femoral artery after Acupressure—in amputation —five days. (Author.) 264 SPECIAL PATHOLOGY AND SURGERY. artery atrophies, and undergoing degeneration into a fibro-cellular cord, as after ligature, thus becomes permanently obliterated. In conjunction with this series of changes, as affecting the blood in the artery, and eventually the vessel itself; there are, however, no changes at the seat of acupressure —no division of the inner and middle coats of the artery, and their inver- sion or reduplication, and no subsequent deposition of lymph with ad- hesion of the divided coats of the vessel; the integrity of the artery remains unaffected by the compression of acupressure, temporarily applied, the needle serving the purpose merely of preventing the escape of blood as primary haemorrhage, while, by arrest of the passage of blood, coagu- lation may be induced, and thus secondary haemorrhage prevented when the needle is withdrawn. A firm, fibrinous, and adherent clot, was found to have formed within five days, and in a main artery—the femoral. In treatment, by acupressure, therefore, the proper period for the safe withdrawal of the needle, may be inferred to be, at that period, if not earlier ; Avithout liability to the occurrence of secondary haemorrhage. (2) With regard to the probability of adhesion taking place between the surfaces of a Avound, the arteries of which are secured by acupressure ; it is alleged that the needles are, as foreign bodies, merely temporary, Avhile their material is less irritating than that of ligatures; and that they are not intended or allowed to produce sloughing of the compressed arteries, whereby foreign bodies of worse character, in the shape of slough-rings of the cellular coats of these vessels, are produced and remain between the raw surfaces—with, moreover, suppuration. (3) Hence, also, the greater probability, apparently, of pyamic infection supervening after ligature. And certainly the observations of Professor Pirrie are here to the point, not a single instance of pyaemia having occurred in his experience where acupressure has been employed by himself or his Hospital colleagues at the Aberdeen Hospital. 4. Torsion of cut arteries, is another method of arresting haemorrhage, which may be regarded as an imitation of another natural process of cure. Torsion is effectual by laceration of the two inner coats of the cut end of a bleeding artery, the outer coat remaining as a loose filamentous sheath, which, entangling the blood and forming a peg, is equivalent to an acci- dentally complete laceration. This procedure originally noticed by Galen, was revived about 1828; in France, by Amussat, Velpeau, and Thierry; and in Germany, by Fricke. In this country, recently, torsion has been practised more generally, and it seems to be attracting increasing attention. Arteries of small size had long since, occasionally, been commanded by a pinch and tAvist with the forceps; but large arteries, as the femoral, brachial, ulnar, and radial, have been effectually secured by torsion, in amputations of the thigh, arm, and fore-arm, as previously practised by Amussat and Velpeau. Occlusion by Torsion, has been specially investigated by Mr. Cooper Forster, Avhose observations are published in the Trans. Clin. Society, 1870. My own observations in one case, death taking place in thirty-six hours, were communicated to the same Society, in 1871. Occlusion con- sists in the folloAving changes :—At the seat of torsion, the two inner coats of the artery are torn across, and reduplicated up the vessel, perhaps in the form of a complete funicular sheath, one-fifth of an inch in length ; and at the upper or smaller opening of this reduplication, or funnel, a conical blood-clot forms, occupying the bore and extending up the vessel WOUNDS OF ARTERIES. 265 ,17?* (Fig. 42). The twisted condition of the artery, itself usually a persistent change, and the reduplicated sheath, of the two inner coats, above, acting as a Aralve, are quite sufficient provision against the recurrence of haemorrhage at the time of operation and subsequently; but there is also the supervention of clot-forma- Fig. 42.* tion from this sheath, and ex- Fig. 43. tending further up the bore of the vessel. Different modes of torsion have been recommended, and are practised. The artery may be draAvn out for about half-an- inch by one pair of common serrated forceps, and its attach- ment seized by another pair of serrated forceps ; the free por- tion is then twisted off by about a dozen turns of the former instrument—the me- thod of Amussat. (Fig. 43.) Or, the end of the vessel may be simply twisted several times, Avithout detaching it; as re- commended by Velpeau and Fricke. This is the method I ordinarily practise, scarcely ever employing ligature to any artery, of whatever size ; it has been much practised also by my colleague, Mr. J. D. Hill, and it is I believe generally preferred. Torsion-forceps are now used ; the instrument being furnished with transversely serrated points, and closed by a slide when the end of the vessel has been seized. Comparison of Ligature, Acupressure, and Torsion.—The occlusive process, in the changes which the artery and contained blood undergo by ligature, acupressure, and torsion, may be thus summarily stated :— firstly, in all three, conical clot-formation and plugging of the vessel, adjoining the line of compression, or of tAvist; and, in acupressure, this is the only provision against the supervention of haemorrhage, when the surgical appliance—the needle—is Avithdrawn. Secondly, in both ligature and torsion, division of the inner and middle coats of the artery, transversely, at the line of operation ; followed by lymph-deposi- tion and sealing of the vessel. This is the only additional provision against the supervention of haemorrhage, when the ligature separates; but in torsion, the tAvist of the vessel is persistent, and reduplication of the divided coats, probably in a funicular form, acts also mechanically, as a valve, against the occurrence of haemorrhage. In relation to the treat- ment of hamorrhage—by acupressure, the formation of a clot-plug might seem an insufficient provision to prevent its recurrence, when the needle is AvithdraAvn, that secondary haemorrhage would then take place; yet the results of experience, already referred to (p. 262), have shown that * Occlusion of brachial artery after Torsion—in amputation—thirty-six hours. (Author.) 266 SPECIAL PATHOLOGY AND SURGERY. this single provision is sufficient, without the additional security of lymph- deposit and sealing of the vessel, as at the line of ligature or of twist; or the extra and mechanical security afforded by the persistency of the tAvist, and the funicular valve of fining membrane. But assuming the liability to the occurrence of secondary haemorrhage to be about equal after either of the three methods of surgical treatment; the tendency to primary union of the flesh-wound, and the prevention of pyamic infection. of the system, must be very different. Torsion has decidedly the advan- tage over either ligature or acupressure, in regard to both these very important considerations. The tAvisted portion of an artery not being killed, as its subsequent adhesion shoAvs, no sloughing of the end of the vessel ensues—when this portion is allowed to remain in the Avound; yet this event necessarily and intentionally ensues after the application of ligature, or accidentally by prolonged acupressure; and no other foreign body is allowed to remain in the wound, for however short a period, to possibly provoke suppuration, as after both these methods of treat- ment. Wounds of Veins.—The same forms of injury may occur as those to which arteries are liable, and they having been already sufficiently de- scribed, need not be repeated. The Signs of any such wound are venous haemorrhage ; the blood of a purple or black colour and flowing in a continuous stream, unlike the jetting of florid red blood from an artery. The force, and in some degree the rapidity, of this stream, are regulated by the size of the vein, or of the aperture in it, by the heart's action, and its effect on the flow of venous blood; and by the presence or absence of certain conditions Avhich favour or retard the free flow of blood through the vessel. Thus, pres- sure on the vein between the aperture and the heart, a dependent position of the part, and muscular action in the course of the current, favour the haemorrhage; Avhile, the opposite conditions retard it. Causes, and Effects of Wounds of Veins.—Like an artery, a vein may be incised or cut with a sharp instrument, punctured with a pointed one, contused or lacerated by a blunt one, or injured by force of a bruising or wrenching kind. The operation of this lesion is, locally,—to induce dif- fuse inflammation of the vein,—diffuse phlebitis, if the wound be an open one, or to produce a collection of venous blood—blood-tumour, if the fluid be imprisoned in the textures. This condition will be described under Contusion. Constitutionally, whether venous haemorrhage takes place externally, or internally into one of the great cavities of the body, its effects are manifested by syncope ; either by failure of the heart's action—cardiac syncope—and thence of the circulation, or by loss of con- sciousness—cerebral syncope; or by both these effects, and their fatal termination if the haemorrhage be sufficiently prolonged. These consti- tutional effects and the probability of death resulting, are proportionate to the quantity of blood lost, not necessarily by its escape from the body, but, even AA'hen lost to the body, as blood in circulation. Such conse- quences are less apt to ensue from venous than from arterial haemorrhage; but another constitutional disturbance is specially liable to occur from an open wound of a vein, and more so, the larger the vessel. Air is thus apt to enter the circulation, attended with a whirling, bubbling, sucking, or lapping sound; the individual feels death-struck, he moans and breathes heavily, becomes very faint, and probably dies, in a few minutes, or at the most, in a few hours. WOUNDS OF VEINS. 267 Reparation.—Wounds of Veins heal by processes apparently analogous to those Avhereby similar Wounds of Arteries are repaired. Treatment.—The arrest of venous haemorrhage may be accomplished, by an elevated position of the part, and the pressure of a compress secured by a few turns of a roller. Cold or astringent lotions are also of some service. Ligature should be avoided, as being apt to induce phlebitis. But this resource may be necessary in the case of a large vein, or if the vessel be so situated that pressure cannot be applied. The treatment of diffuse inflammation of a wounded vein will be considered under the head of Phlebitis ; and the remedial measures appropriate to the formation of a blood-tumour, in connexion with Con- tusion. Entrance of Air into Veins.—The fatal result or the extremely perilous symptoms arising from the forcible introduction of air into the veins of animals, had long been knoAvn ; and Avas at length made the subject of experimental observation by Morgagni, Valsalva, Bichat, and Nysten. But, in Surgical Practice, the accident first occurred in the experience of M. Beauchesne in 1818, during an operation for the removal of a tumour from the loAver part of the neck. It was necessary to dis- articulate and raise the clavicle; and while this was being done, the patient became faint, exclaimed " I am dying," and expired in less than a quarter of an hour. Dissection revealed a small wound in the internal jugular vein at its junction with the subclavian and the entrance of air through that wound caused the fatal result. The accident has since hap- pened in the practice of Mirault, Clemot, Roux, Magendie, Castara, Dupuytren, Delpech, Begin, B. Cooper, Erichsen, Warren, Mott, Stevens, and other Surgeons, both in Europe and America. A Com- mission of the French Academy was appointed to investigate the subject; and the names of Magendie, Amussat, Wattmann, and Cormack, are distinguished for the light their labours have thrown on the pathology of the entrance of air into veins. Symptoms.—The local phenomena consist in a peculiar sound, of a hissing, gurgling, lapping, or sucking character, produced by the entrance of air, and the appearance of bubbles about the wound in the vein. The constitutional effects are equally remarkable ; the patient is suddenly seized Avith great oppression in breathing, and extreme faintness, convul- sive struggling, and a horrible feeling of terror and impending danger, inducing him to exclaim that he is dying. A churning noise is heard in the heart, synchronous with the ventricular systole; and the hand applied to the chest, perceives a peculiar bubbling, thrilling, rasping sensation, produced by the air and blood being whipped together within the ven- tricle. The heart's action becomes extremely feeble, and the pulse almost imperceptible. When only a small quantity of air has entered the circulation, the symptoms may pass off and the patient rally. A larger admission of air speedily causes death, during the convulsive struggling, or without convulsions, as if by simple syncope. The period at which death occurs varies, from a few moments or minutes, to several hours. When the patient survives, some hours elapse usually, before con- sciousness and strength are restored. In some cases, after recovery from the immediate effects of the accident, death has ensued from pneumonia. The mode of death seems to be essentially asphyxia, by arrest of air- bubbles in the capillaries of the lungs, mechanically obstructing the pulmonary circulation; thence cutting off the systemic circulation, and 26S SPECIAL PATHOLOGY AND SURGERY. the supply of arterial blood to the brain, followed by syncope. Thus the heart's action continues, after respiration has ceased; and at last failing from want of its necessary stimulus, arterial blood, this organ is the ultimum moriens. Cause.—Air enters the veins only during each act of inspiration ; and in consequence of a tendency to the formation of a vacuum within the thorax, more particularly in the pericardium, during inspiration. Thence a sucking action, or " venous inspiration," in the veins within and near the thoracic cavity; extending only to where the coats of the veins col- lapse. This area is limited to that part of the root of the neck and axilla Avhere the venous flux and reflux of blood are perceptible, and the space in which it occurs has been called " the dangerous region." Circumstances favouring the accident:—1. The site of the wounded vein being in the dangerous region. 2. Canalization of a vein ; owing to its coats being thickened by morbid deposit, or adherent to condensed, consolidated surrounding textures, or by spasmodic contraction of muscles ; any of these three conditions having the effect of converting a vein into a rigid, uncollapsing tube. 3. Traction on the vein. 4. A stretched position of the part operated on. 5. The form of the wound. 6. The position of the vein in the wound ; a vein cut in the corner of a wound being apt to gape, as Dupuytren's case demonstrated. 7. Deep inspira- tion. Treatment.—Preventive measures consist—in making pressure on the cardiac side of the wound, during operation in dangerous localities; maintenance of a relaxed position of the part, and prevention of the stretching of veins. Any vein of considerable size, and especially in which the venous pulse is perceptible, should be avoided as much as pos- sible. Feeble inspiration is desirable, and this is best secured by the influence of chloroform ; tightly bandaging the chest to prevent deep inspiration, as some have recommended, is a perilous precaution. Curative treatment comprises the fulfilment of the following indications :—1. To maintain an adequate supply of blood to the brain, for the prevention of death by syncope. The patient should be placed recumbent, with the head low, and pressure should be made on the axillary and femoral arteries, so as to direct the circulation towards the brain. 2. To maintain the action of the heart by artificial respiration, and friction at the praecordial region. 3. To promote the removal of obstruction in the pulmonic capillaries, also by artificial respiration. 4. After recovery, to treat the tendency to inflammation of the lungs. CHAPTER XV. CONTUSION.--CONTUSED AND LACERATED AVOUNDS.—PUNCTURED WOUNDS. Contusion.—Structural Condition.—Contusion is a laceration of the soft textures, subcutaneously • the skin remaining unbroken, whereby the textures, thus injured, are protected from the air. This kind of lesion, therefore, is the connecting link between other subcutaneous lesions, by laceration, as simple fracture and dislocation; and openly lacerated, or contused wounds, compound fracture and similar dislocation; the turning CONTUSION. 269 point being, exclusion from, or exposure to, the action of the air. Sub- cutaneous laceration of the soft textures is necessarily attended Avith some haemorrhage, also subcutaneous, but which extends in Avar ds accord- ing to the depth of the contusion. The degree of laceration is propor- tionate to the force applied externally, and to the molecular cohesion of the textures affected; the quantity of blood effused, is regulated, partly by these circumstances, but chiefly, by the vascularity of the textures ; while, the effusion itself is finally determined by the resistance offered by the textures which, with the blood accumulated, together act as a com- press upon the lacerated vessels. Signs.—The blood, diffused into the textures interstitially, and especially into the cellular texture, is said to be extravasated ; instead of being discharged out of the body as in ordinary haemorrhage. Any portion of the blood which has accumulated in the cellular texture under the skin, or is thus more immediately subcutaneous, is made visible through the integument; and hence the appearance of a livid or black discoloration, the ordinary appearance of bruise, as seen in the first instance. If only a small quantity of blood be extravasated here, or elsewhere, the appearance is designated ecchymosis. Blood extravasated in considerable quantity may still present the appearance of bruise, but have also the fluid and fluctuating character of an abscess. A hard cir- cumscribed boundary can also perhaps be felt. Puncture, in appropriate situations, Avith a grooved needle and examination of the fluid with the microscope, will determine a doubtful diagnosis. The discoloration of contusion bears a general resemblance to gangrene, but the temperature and sensibility of the part are retained, at least in a higher degree than in that condition. When extravasation of blood has taken place, deeply, and possibly into internal organs, it is declared by functional disturbances of a less definite character, and which of course vary with the part to Avhich contusion thus extends. Causes, and Effects of Contusion.—External force in the shape of pressure or a blow, may directly produce contusion ; or the force may be applied indirectly, at some distance from the part affected. But the state of the textures may predispose to this kind of lesion. The elastic firmness and comparatively bloodless condition of the flesh of a prize- fighter, Avho has undergone " training," contrasts favourably with the flabby bloated face of one who is " out of condition," as that of the intemperate debauchee, Avhich is ever bordering on ecchymosis. The operation of this lesion, locally, is identified with its course; while its effects constitutionally are those which arise from other forms of Injury, and haemorrhage; but the syncope arising from contusion is due more to the injury, itself possibly extensive and severe, than to the extravasation of blood. Therefore, the shock of injury, as manifested by the nervous system, predominates; or tetanus may supervene. [P. p. 432.] Course.—The natural course of Contusion is twofold ; inclining, on the one hand, to reparation subcutaneously ; on the other, to sloughing, the formation of an open Avound, and reparation subsequently by the process of suppurative granulation. Thus, no perceptible alteration may take place in a contused part, the bruised appearance remaining for a variable period ; but absorption supervening, the originally purple or livid discoloration of a bruise fades away into a greenish or yellowish hue. Blood extravasated in considerable quantity may also remain 270 SPECIAL PATHOLOGY AND SURGERY. stationary, as a bag of fluid. But it generally undergoes changes of consistence, becoming thin and serous, and enclosed in a fibrous cyst, or thick and dark like treacle, constituting a sanguineous tumour—haematoma; or Avith coagulation, organization of the clot may ensue by the develop- ment of new blood-vessels. In either of these subcutaneously reparative alterations, the blood corpuscles undergo disintegration to some extent; and hence, apparently, the changes of colour, followed by absorption ; and it can scarcely be doubted that the damaged structural condition of the textures is more or less reinstated. But the intimate nature of all these reparative alterations, after contusion, requires further investigation. Lastly, the most obvious change may be destruction, prevailing over any reparative effort; the blood, acting as a foreign body, induces inflamma- tion, the products of which, commingling, form a bloody purulent fluid, extravasated amid the disintegrated textures. Gangrene is imminent, an event the more apt to ensue according to the severity and extent of con- tusion ; gangrenous disintegration of the textures then appearing either as sloughing, or as traumatic gangrene, and converting the subcutaneous lesion into an open lacerated wound. Haemorrhage, superadded to the blood originally extravasated, is another adverse issue, but less common, unless in internal organs. Reparation by the process of suppurative granulation will be de- scribed more appropriately in tracing the course of a contused or lacerated wound. Treatment.—The earliest occasion for interference is determined, not by the presence of contusion, which is naturally disposed to undergo reparation subcutaneously ; but it depends on the degree of contusion and the quantity of blood extravasated. A slight ecchymosis disappears spontaneously; a more severe bruise may need help. The indications are, in the first instance, to promote absorption, with- out any breach of the integument. Various topical applications have reputed efficacy. Arnica, I think, possesses some virtue. The tincture diluted, in the proportion of an ounce to half a pint of Avater, is perhaps more efficacious than spirit lotion, or any other cold evaporating fluid. Leeches are not merely useless to withdraw the blood, congealed and infiltrated; but by admitting air, and thus inducing decomposition, they are positively noxious. Moreover, they are apt to excite sloughing of the skin. Should gangrene threaten, whether from the blood acting as a foreign body, from the severity and extent of the contusion, or from both these conditions co-operating; then, indeed, incisions, early and free, are imperative, to give vent to blood and pus which would otherwise rapidly putrify, and to prevent sloughing, or its progress. In short, any attempt to aid restoration is now too late or inappropriate, and the rule of treatment should be to anticipate if possible, or at least accompany, the work of destruction, and forthwith remove its results. Accordingly, in the event of traumatic gangrene, amputation may become justifiable, as an extreme and rare resource. Contused and Lacerated Wounds.—Structural Condition.—These forms of Injury, although nominally distinct, in regard to the kind of force by which they are produced, are essentially the same. A contused or a lacerated Wound, is a sudden disintegration of the soft textures, with exposure to the action of the air. In the latter respect, Avounds of this kind differ from contusion,—a subcutaneous lesion ; and in virtue of the former particular, they differ from compound fracture and compound UUJNTUSED AND LACERATED WOUNDS. 271 dislocation, Avherein the lesion itself is not exclusively laceration of the soft textures, these parts being involved only by the injury. The characters of a lacerated wound are peculiar. It presents a torn irregular surface or cavity, Avith more or less surrounding swelling and discoloration, owing to effusion of blood beneath the skin, or ecchymosis. Haemorrhage from the wound itself is inconsiderable ; the vessels being lacerated. With these external appearances, the degree of pain ex- perienced Avould seem to be inversely proportionate to the extent and depth of the laceration; for this kind of injury implies a corresponding destruction and death of the textures. The pain is heavy and aching. The structural alterations produced by laceration, and thence the characters of a lacerated wound, are somewhat modified by the exten sibility, elasticity, contractility, and other properties of the textures. The resulting appearances are most conspicuous when a limb is drawn off, as by machinery; or abruptly struck off, as by gun-shot injury. Some textures are comparatively unyielding, and their torn extremities hang out of the stump; others break off short within the general mass. Thus, the skin being tough and elastic, it either yields higher than the included textures, or it retracts, exposing them; the muscles protrude and are everted ; the tendons resisting with greater tenacity, they hang out of the stump, or giving way higher up, they are pulled out of their sheaths; nerves, for the most part break off at the surface; the vessels, especially arteries, possessing considerable elasticity, are drawn out to some length, their inner and middle coats yielding, while the external coat is prolonged over them; and their torn ends retracting, they become less pendent and exposed than any other part of the stump; lastly, the bone, having broken off abruptly, it forms the most prominent point. The stump, therefore, presents an irregular conical form, with the truncated bone as its apex. Causes, and Effects of Lacerated Wound.—The force applied may be chiefly lacerating, as when an arm is draAvn in between two revolving cog-wheels ; or it may be chiefly contusing, as the action of a cannon- ball or other projectile. In either case the part is damaged beyond, and perhaps far beyond, the apparent extent of injury. The constitutional effects of a contused or lacerated wound are those already noticed with reference to other forms of Injury, and haemorrhage ; but the syncope arising from such lesion is due more to the injury, itself possibly extensive and severe, than to the extravasation of blood. The shock of injury is always severe, sometimes overwhelming; tetanus also is apt to supervene, especially after any such wound of the hand or thumb, of the sole of the foot or of the toes. [P. p. 442.] Locally—the textures, disintegrated by violence, inevitably die, to a greater or less extent. This event, Avhich is strictly speaking traumatic gangrene, on hoAvever small a scale, takes place in one of two ways, or both may co-operate. Severe contusion or laceration kills the part out- right ; or it does so indirectly, by damaging the blood-vessels some distance off; in Avhich case mortification is occasioned by an intervening and internal condition—deficient supply of blood to the part. In both cases, gangrene is immediate, or at least immediately commences; it evinces no tendency to spread beyond the seat of injury, and, in due time, is defined by sloughing, or by " a line of demarcation" Avhen the injury is more extensive. Course.—(1) Gangrenous Inflammation almost invariably supervenes, 272 SPECIAL PATHOLOGY AND SURGERY perhaps extensively, and thus textures or a part Avhich may not have been killed more immediately by the injury, die subsequently. Y'et such gan- grene also is4imited to the seat of injury, and is defined by sloughing. Gangrene may, indeed, supervene on a contused or lacerated wound, without any apparent or notable inflammation, and extend far beyond the seat of injury; a whole limb speedily falling into gangrene, which spreads rapidly and is not determined by a line of demarcation. This, Avhich has been named spreading traumatic gangrene, is traumatic only in that injury is the immediate or exciting cause; but its spreading and unlimited character points to some blood-condition, in operation, as the essential cause. In fact, this gangrene is the local manifestation of a constitutional condition, rather than the consequence of a local cause in operation. Its pathological significance is corroborated by two facts— that the contusion or laceration is quite subordinate in extent to the supervening gangrene ; and that it occurs in those persons especially who have albuminuria, a state of urine indicative of the retention of excre- mentitious matters, chiefly urea, in the blood. Either form of gangrene is always humid or moist, unlike the dry species of which senile gangrene is the representative. When a part is killed immediately, the appearances are those of the most severe con- tusion or bruise; when less immediately completed, as by injury to the blood-vessels, the symptoms are the same, but proportionately more gradual; and when gangrenous inflammation supervenes, the symptoms are those of inflammation rapidly passing into gangrene. But when spreading traumatic gangrene takes place, the phenomena are those of a severely poisoned wound. Gangrene is announced by great tension and livid or purplish-black discoloration, which although most con- spicuous about the seat of injury, extends rapidly upwards and down- wards ; its progress being preceded by a slighter oedematous swelling and greenish-yellow discoloration. This, in advance, is a dying part; that, in the rear, is already dead. Emphysematous crackling, under pressure with the finger, soon leaves no doubt that death and decomposition go hand in hand. The accompanying constitutional symptoms are those of typhoid blood-poisoning; and the disease generally terminates fatally in a very few days, not later than whenever the gangrene shall have spread to the trunk. (2) Reparation.—In favourable contrast Avith any tendency to death ; the wound may evince a disposition to heal by primary adhesion, or, any irrecoverable part having sloughed and separated, the exposed surface heals by suppurative granulation. The process is, then, briefly this :— The local circulation is temporarily suspended. A thin coagulable lymph oozes from the surface, and forms a fibrinous film, in which white corpuscles of the blood abound. Thus the Avhole surface becomes glazed over, excepting perhaps any portion of fat or bone, which textures yield scarcely any, if any, such lymph. A period of inactivity follows, lasting from one day to ten or more, but varying with each particular texture in the Avound. Some further oozing of lymph and thickening of the film may, hoAvever, continue during this period. At length, a distinct afflux of blood more than restores the circulation around the seat of injury. Repa- rative lymph begins to flow, Avhich mingles with or displaces that which has hitherto glazed the wound. This lymph undergoes the same process of organization as in healing by adhesion—namely, self-development into fibro-cellular tissue. The deepest cells are most advanced ; they are CONTUSED AND LACERATED WOUNDS. 273 elongated nearly into fibres. (Fig. 44.) The superficial ones remain in a rudimental state, and at length acquire the character of epithelial cells. Capillary blood-vessels spring from below, forming loops, as also seen in the figure. Each new vessel is constructed by the outgrowth of two pouches from a parent vessel. The pouches, crammed with blood-cor- puscles, shoot upAvards, and curving inwards, never fail to meet exactly in apposition, neither segment overshooting. They coalesce by absorp- Fig. 44. tion of the partition at the junction of their closed ends, thus completing a vascular loop, through which the blood, diverging from the mam current and rejoining it, is continuously propelled. If, in the construction of any such vascular arch, the pouches burst, the process is then completed by the propulsion of the blood-corpuscles, the current of blood from the parent vessel being directed so skilfully as to channel a curved passage through the fibro-cellular tissue. Nerves and lymphatics do not appa- rently enter the substance of granulations. The process of development having finished, healthy granulations are seen in the shape of small conical papillae, of a glistening red colour when free from pus The pus cells in suppurative granulations are either degenerate or immature granulation-cells. If the former pus represents thi superficial portion of organized granulation material which, having lived its time, passes off, just as epithelial cells are detached. If immature granulation-cells, pus represents the superfluous portion of organizable material, which never reaches maturity. This is the more probable inter- pretation, considering the structural similarity or identity of pus-cells. As immature granulation-cells, pus ceases to be secreted Avhen the granu- lations come to the level of the skin, for then, the wound or chasm being filled up, no more organizable material is needed. Sometimes during the granulating process, granulations from opposed surfaces meet together. They may then unite-a conjunction designated "secondary" adhesion, to nominally distinguish it from adhesion primarily, as between the surfaces of an incised wound. But it takes p ace in he same W by the development of fibres out of nucleated cells and the nSrchanie of capillary blood-vessels through this medium of communica- tion The contractile force of granulations is supplemental to reparation n bringing down the marginal skin to their own level and diminishing he aref of the wound. Thus, then, by their actual growth and possible 274 SPECIAL PATHOLOGY AND SURGERY. coalescence, aided by their contraction, granulations and skin at length become even. Cicatrization commences, its purpose being to cover the granulations with skin. The marginal skin advances as a white line, preceded by a translucent bluish-white line of cuticle around the circumference of the sore. Converging, the surface gets covered; sometimes little islands of new skin form here and there, which coalesce, and shorten the process of marginal cicatrization. Newly formed and healthy cicatrix is ^ thin and red, with a stretched, shining aspect, and not so supple and elastic as true skin; somewhat depressed, sometimes elevated, and always moveable. It contracts for a long Avhile, and with considerable force, especially after burns, and acquires a pearly-white colour. It gradually becomes more supple, elastic, and moveable as part of the integument. Nature has healed, and almost effaced, the Avound. The Prognosis of Contused and Lacerated Wounds may be gathered, as Avith regard to other injuries, from a due consideration of their nature and course. It is less favourable than that of an Incised Wound; owing to the kind of structural disorganization in contusion or laceration. Gan- grenous disintegration of the textures in a greater or less degree, is inevitable ; or gangrenous inflammation, with sloughing and suppuration. The extent of the lesion will, therefore, much affect the issue. Spreading gangrene is an adventitious condition, but it is the most unfavourable consequence of contusion or laceration, as implying the co-operation of a constitutional cause. Healing by primary adhesion is exchanged for the slower and perhaps less effectual process of suppurative granulation ; yet the latter being another mode of Reparation, must be regarded as an eventually favourable element in the prognosis of the lesion under con- sideration. Treatment.—In all superficial wounds, contused or lacerated, and especially of vascular parts, as the scalp ; the chance of primary adhesion taking place, to some extent, is not improbable, and it may be solicited with good prospect of success. Accordingly, in the first instance, the treatment is the same as for an incised wound. Foreign bodies, such as grit, portions of clothing, having been removed by a wet sponge or stream of Avater ; replacement of the torn textures and their retention in position by the usual surgical appliances, are the immediate rules of treatment to be observed. The unknown power and resources of this or that mode of reparation, in different parts of the body and in different individuals, will ever restrain the pathological Surgeon from hastily foregoing the pro- bability or possibility of the more advantageous mode in any case. But the disintegrated textures inevitably die, to a greater or less extent. Hence the kind and amount of assistance required. In the event of primary adhesion having failed entirely, and in all deep and extensively contused Avounds, it becomes necessary to actually encourage and aid the process of sloughing, in order to bring into operation that of healing by granulation. The separation of sloughs is favoured by warmth and moisture, in the shape of a light poultice or spongio-piline epithem. The reparative process needs little assistance; position, rest, and protection from the action of the air by carbolic acid dressing, will suffice for the granulating of any healthy wound. Deep and extensively contused or lacerated wounds of either limb are conditions which, in relation to profuse suppuration or gangrene, must be considered both Avith regard to the preservation of the limb and the life. CONTUSED AND LACERATED WOUNDS. 275 Amputation.—The propriety of amputation has regard to both these issues, Avhich will be more advantageously considered in connexion with compound fracture and dislocation. If gangrene be allowed to supervene, life is endangered ; if the limb be removed before the supervention of gan- grene, it may have been sacrificed by such untimely interference. The compromise of these two considerations is better determined by pathology than by empirical experience :— (1) If the whole substance of a limb be involved by the injury, gan- grene is inevitable ; amputation, therefore, is imperative to intercept this event, and thus preserve life. (2) If, however, the injury be less ex- tensive, and gangrene not inevitable ; what then ? Various pathologico- anatomical conditions—less than the whole substance of a limb being involved—are defined in surgical Avorks ; respecting which forms of injury, experience is said to justify amputation, in the first instance, con- sidering the probable supervention of gangrene. But this event can never be foretold with absolute certainty in different conditions of injury; the resources of reparation and the reserve constitutional poAver of dif- ferent individuals being unknown. Having regard, therefore, to the pre- servation of the limb—in cases short of its irreparable destruction—the actual supervention of gangrene is the only ground of assurance as to the urgent necessity for amputation. This compromise between limb and life may be thus stated :—Avhen- ever a limb is destroyed, by injury, and life would be perilled by gan- grene supervening, (primary) amputation is imperative; whenever a limb is not entirely destroyed, the rule should be, to give the limb its chance of recovery, by waiting for gangrene; but in that event (secondary) am- putation becomes necessary, and further delay would peril life, without the compensating probability or possibility of preserving the limb. Duly weighing both these conditions; the Surgeon will ever be prepared to estimate the urgency of amputation in any particular form of contused or lacerated wound—and otherwise than when destructive of the whole substance of a limb. The subordinate conditions of injury, necessitating amputation, are thus enumerated in Mr. Erichsen's work on Surgery. It should be observed that some of them are, not conditions of contused or lacerated Avound alone, but as associated with Fracture, compound, (1) If the soft parts be extensively stripped away from the bones, though these be entire, so much sloughing and suppuration Avould ensue as to leave a useless limb, and amputation should be performed. (2) If a large artery, as the femoral, is lacerated at the same time that the soft parts are extensively injured, and the bone fractured, amputation is required in order to prevent the occurrence of gangrene. (3) If the knee be largely opened, with laceration of the soft parts, and perhaps fracture of the contiguous bones, the limb must be ampu- tated. Corresponding injuries of the ankle, shoulder, and elbow joints, may admit of resection rather than of amputation. (4) Bad crushes of the foot have a great tendency to run into gan- grene, and hence require amputation. In the hand, on the contrary, very extensive injuries are often recovered from, without this operation being necessary; and in many cases partial resection may be substituted for it. The time also, as Avell as the conditions, for the performance of ampu- tation is equally represented by the foregoing rules. Amputation for injury, in general, is commonly divided into Primary and Secondary; t 2 276 SPECIAL PATHOLOGY AND SURGERY. the primary being that which is performed during the first twenty-four or thirty hours, before any inflammation has commenced ; the secondary being amputation performed after that period, or at least before the super- vention of inflammation and suppuration. Amputations performed in the intervening period, betAveen twenty-four hours and inflammation, are sometimes designated intermediate. With regard to contused and lacerated wounds; the proper time for amputation under different circumstances, is expressed by these terms—primary and secondary, as having reference to the performance of the operation before or after the occurrence of gan- grene ; in accordance with the rules already laid down. Part for Amputation.—In the event of gangrene, the seat of amputa- tion or the portion of limb to be removed, should not be determined by waiting for the formation of the line of demarcation between the living and dead parts. Amputation must be performed at once, and sufficiently high above the seat of injury to prevent the recurrence of gangrene in the stump. The foregoing considerations relate exclusively to purely traumatic gangrene. Spreading traumatic gangrene being the local mani- festation of some morbid condition of the blood, its supervention is so far less likely to be intercepted by the primary amputation of the injured part. On the other hand, gangrene appearing in the stump, would frus- trate the intention of the operation with regard to the preservation of life. When spreading gangrene has supervened, the Surgeon is placed in this dilemma in regard to the part for amputation :—if the operation be per- formed without waiting for the line of demarcation, gangrene will probably reappear in the stump and death ensue ; if the operation be postponed, for this purpose, the gangrene spreads rapidly up to the trunk, and then death is inevitable. Considering that the injury is the exciting cause of this gangrene, amputation had better be performed at once, and at some height above the apparent seat of injury. But, in selecting a sound part of the limb, and not merely that which may recover itself as a stump ; it must ever be remembered, that Avhile the damage done by contusion or laceration is more extensive than may appear on the surface, the destruc- tion wrought by spreading gangrene, especially in the cellular texture, has even a wider range up the limb, than as declared by any discolora- tion of the skin. The safest parts for amputation are, probably, at the shoulder joint, when the arm is involved; and in the upper third of the thigh, Avhen the leg is affected as far as the knee. The after or constitutional treatment is fully considered in connexion with the general pathology of Gangrene. Punctured Wounds.—Structural condition.—A Punctured Wound is a more or less contused and lacerated wound; varying in depth, but of greater extent in this direction than superficially. Structures may thus be injured far beyond what appears to be the extent of injury, by the aperture in the integuments. Other kinds of Wound—the incised and the purely contused or lacerated—may indeed be complicated by their depth ; a punctured wound is characterized by this additional element. Thence, penetration of an artery and the formation of traumatic aneurism, may complicate a punctured wound in any part. Penetration of the brain complicates a punctured wound of the skull; and similar injury of the lung or heart, or of one or more of the abdominal viscera, may complicate a punctured wound of the thoracic or abdominal cavities, respectively. The external characters of a punctured wound are comparatively unim- PUNCTURED WOUNDS. 277 portant, and not characteristic. Varying in size, from a pin's point to a bayonet-thrust or an aperture of larger size; its shape differs with the form of the penetrating instrument; the margin of the aperture is irregular and the surrounding integument bruised, if the wound was produced by the penetration of a blunt-pointed instrument; and this laceration and contu- sion are the more conspicuous if the weapon was of increasing size from the point upwards, as a bayonet. The haemorrhage cannot be estimated by the quantity of blood which escapes externally. The narrow track of a punctured wound and laceration of the textures, rather impede the escape of blood, and are favourable to the formation of traumatic aneurism. If the wound extend into an internal cavity, as the thorax, haemorrhage may take place yet more abundantly without a corresponding escape of blood from the aperture externally. The Symptoms connected with the penetration of particular parts, perchance the viscera, are specially significant, in virtue of the function of the part which is thus involved; but, as not pertaining to the general pathology of Punctured Wound, such symptoms are here omitted. Each successive injury, in depth, is less open to detection, owing to the narroAV track of the wound. The diagnosis, therefore, must be determined by functional symptoms; and it will be remembered that structures of vital importance, possibly, may be implicated, beyond the otherwise apparently simple puncture, viewed externally. Causes, and Effects of Punctured Wound.—Any pointed instrument, sharp or blunt-pointed—e.g., a pin, an old rusty nail, a pen-knife, or a bayonet—represents the whole class of causative agents. Contusion and laceration are proportionate to the bluntness of the penetrating instrument. The constitutional effect of a punctured wound, consists partly, of syncope due to haemorrhage ; partly and perhaps principally, of shock to the nervous system ; and here again, both are generally disproportionate to the apparent importance of the local lesion, which, by its depth may in- volve large blood-vessels and nerves, and possibly implicate a vital organ. Tetanus is another constitutional condition not unlikely to occur. Course.—Sloughing ensues, more or less in extent, along the track of the wound, accompanied Avith suppurative discharge; but, eventually, it heals by granulation. If the textures are not much contused nor lace- rated, the wound may heal by primary adhesion ; and this, although the depth of penetration may have been considerable, extending even into a great cavity and involving an important organ. Thus, in one case, under my observation, after a stab in the back with a fork, Avhich entered the lung ; union of the flesh-wound speedily ensued, and the lung-symptoms also subsided. In another case, after a similar stab in the loins, penetrating the kidney ; this mode of healing occurred, and the haematuria disappeared. Other remarkable cases are on record [P. pp. 154 and 766]. Apart from this general vital history, a punctured Avound extending into any internal organ, exhibits a series of phenomena peculiar to the particular organ implicated ; and thence the completion of the vital history of this form of injury, as occurring in different parts of the body, belongs to Special Pathology. Prognosis.—The prognosis of Punctured Wound is partly analogous to that of any other contused or lacerated wound. It is unfavourable in so far as the kind of structural disorganization is that of contusion or laceration. Sloughing and suppuration to some extent are almost inevitable. The presence of any foreign body in the wound has a 278 SPECIAL PATHOLOGY AND SURGERY. similar influence. But the prognosis is specially unfavourable according to the depth of the wound, or the number and functional importance of the parts implicated, as complications of the Avound. Injury to large blood-vessels, nerves, or an internal organ, are thus, severally, un- favourable conditions; and proportionately to the importance of the functional disturbances thence arising. The subsequent course of a punctured wound, in its undergoing reparation by suppurative granulation, is an eventually favourable ground of prognosis. Treatment.—The first indication is to arrest haemorrhage, which obviously claims immediate attention when it occurs in any considerable quantity. Pressure, by means of a compress, Avill generally prove sufficient, unless a large artery be punctured, when it Avill be necessary to ligature the vessel above and below the aperture, by cutting down in the track of the wound, if it can possibly be thus secured. The removal of any foreign body is another obvious indication, whenever it can be safely fulfilled. A portion of clothing may have been thrust so deeply into the wound, and possibly into some internal organ, that its presence cannot be ascertained Avith certainty, nor its removal effected Avith safety, and without unwarrantable mutilation. Guided by the processes of reparation, healing by primary adhesion should be attempted in all cases; but the prospect of success will depend on the comparatively simple character of the wound, by the less circum- ferential contusion, the absence or removal of any foreign body, and the arrest of haemorrhage. Failing in most cases to induce adhesion, the process of suppurative granulation is the alternative to be solicited, as in the usual treatment of a contused or lacerated wound. CHAPTER XVI. GUNSHOT WOUNDS. Gunshot Wounds.—Structural Condition.—Of Complicated Injuries, none are more interesting and important than Gunshot Wounds. But they chiefly concern the Military Surgeon, although the general Surgeon may occasionally be called upon to undertake the charge of such injuries in civil practice. It Avill, therefore, be doubly necessary to fully consider the guiding elements of their pathology and treatment. Gunshot wound is, essentially, a contused and lacerated wound; but varying in extent and depth. The latter element is always a critical consideration. Structures may thus be injured far beyond what appears to be the extent of injury, in connexion with the aperture or apertures in the integuments. If any part, as a limb, be shot away entirely, as by a cannon-ball, the extent of injury is more openly declared. Other kinds of wound—the incised, and the purely contused or lacerated— may, indeed, be thus complicated; a gunshot wound is characterized by either additional element. Thus, penetration of an artery, with the formation of traumatic aneurism, may complicate a gunshot wound in any part. Penetration of the brain complicates a gunshot wound of the skull; and similar injury of the lung or heart, or of one or more of the abdominal viscera, complicates a gunshot wound of the thoracic or GUNSHOT WOUNDS. 279 abdominal cavities respectively. Compound Fracture or Compound Dislocation not unfrequently complicate the more severe forms of Gun- shot injury. The course of a ball in the body is determined by its shape and velocity. The round musket-ball—formerly in use exclusively, and propelled with a velocity which scarcely reached eighty yards, revolving, also, on its axis at right angles to its transit—was turned aside by the slightest obstacle. On striking the body, the resistance offered by clothing, or, on penetrating the skin, by a bone, and, indeed, the different resisting media of different structures, would deflect the ball from its course, and make it assume a circuitous and perchance most extraordinary route; ultimately lodging in the body in many cases. Various remarkable examples are recorded by authors on gunshot wounds.* NoAvadays, the cylindro-conoidal rifle-bullet, generally used, and propelled with a velocity true at 1000 yards or more, pursues its course straight through the body, and out again, in most cases. An apparent deviation is sometimes due to the Surgeon omitting to view the patient in the position he Avas when the ball entered ; and, occasion- ally, though rarely, a real deviation, possibly a circuitous course, is caused by an accidental concurrence of circumstances, especially when the velocity of a conoidal bullet has become diminished. Of the various textures, none suffer so much damage as bone by the penetration of a conoidal bullet. Piercing and passing through the soft parts, it splits and comminutes any bone in its way, producing fissures which extend into neighbouring joints; the greater destructiveness of this shaped projectile, resulting from its wedge-like action, and the peculiar resistance offered by the osseous texture. The bullet itself becomes somewhat changed in shape; its apex being flattened and reverted, if it strikes point-blank; or planed from its apex towards its base when it strikes parallel to its line of flight. Foreign bodies, of various kinds, are often lodged in a gunshot wound, and not unfrequently lie deeply buried; thus constituting another complication. The lodgment of any foreign body is determined by its shape and velocity, chiefly by the latter circumstance. A conoidal ball, with a considerably reduced speed before entering the body, will lodge, more or less deeply; while a round ball, although at full speed, having taken a circuitous route in the body, may become expended, and thus effect a lodgment. Bullets scattered from canister or spherical case, are liable to lodge; owing, apparently, to disturbance of their course in the primary discharge, and secondarily, by explosion of their containing case. (Longmore.) Grape-shot lodge occasionally, and possibly after a very devious course, in the body. More rarely, a cannon-ball lodges, and remains concealed. A ball Aveighing 8 lbs. was buried in the thigh, and discovered only by amputation. (Guthrie.) In another case, a ball Aveighing 5 lbs. was found also in the thigh by amputation. (Larrey.) Penetrating fragments of shell, if projected edgeways, almost invariably lodge, and are frequently concealed ; of which some remarkable instances are mentioned by Mr. Longmore.f In exceptional cases, a small scale may be detached from a leaden bullet, and this lodges in the wound. Such portions may occur, * System of Surgery, 1861, ed. by T. Holmes, art. by T. Longmore. f Op. cit. p. 15. 280 SPECIAL PATHOLOGY AND SURGERY. irrespective of the shape of the bullet, from a cylindro-conical as Avell as from a round bullet; and instances of either kind came within the experience of the last-named authority during the Crimean war. Other kinds of foreign bodies, and of various shape, as gravel, bits of wood, portions of clothing, &c, are not unfrequently found, or remain deep in a gunshot Avound; any such substance being additional to the projectile, or the only extraneous substance. A portion of the body of another individual close at hand, may be struck off by gunshot injury and driven into the one who is the subject of examination. Any such fragment is thus introduced by indirect participation in the gunshot injury. A double tooth, belonging to a comrade was found embedded in the eyeball, in one case ; a portion of the jaw of a companion was driven into the palate in another case; while, in a third case a piece of the skull was found impacted between the eyelids, the fragment having been shot off the skull of a soldier close by. And, generally speaking, the fragment thus introduced comes from a corresponding region of the body struck by the shot. (Longmore.) Signs.—The external appearances produced by gunshot wound, will depend on the size of the projectile and its velocity. Number of Apertures.—A small penetrating body, as a bullet, pro- duces ;—(a) An aperture of entrance, and, if the ball lodges, this is the only aperture. But, the ball may have passed round and out at this aperture ; or, it may have rebounded owing to the elasticity of the part struck, as the cartilages of the ribs ;* or, having lodged temporarily, it may have been withdrawn in a pouch of clothing.y There being only one aperture is, therefore, no sure sign that the ball has lodged, (b) Two openings—one of entrance, another of exit—are produced if the ball penetrates with sufficient velocity to pass through the limb or body, (c) More than one, perhaps several openings of entrance are produced occa- sionally. Thus, a bullet having first struck any hard resisting object, and split into pieces, two or more portions may recoil and wound a bystander; producing as many entrance-apertures. In one such instance, a ball split into five pieces by first striking against a rock; and all five portions entered the body of a soldier a few paces off. But, the number of openings are not necessarily the same as that of the balls which penetrate. For example, of three balls, two may have the same aperture of entrance, and of exit also. This coincidence happened in the case of a youth who was shot through the abdomen; " that three balls went through him was evident, for they afterwards made three holes in the wainscot behind, but two very near each other." (Hunter.) (d) More than one, perhaps several openings of exit are formed in some cases. Thus, a bullet having struck a ridge of bone and split into pieces, two or more portions may pass through.; producing as many exit-apertures. In one instance, a ball having split into two pieces by striking against the sharp crest of the right tibia; both portions passed through the calf of that limb, forming two openings of exit, and then severally entering the other calf, produced five openings altogether.*; A portion or portions of a split ball may lodge. Instances of this kind are recorded, where the ball had struck the edge of the patella, or the spine of the scapula.§ In like manner, Avhen several balls, say three, have entered; one or more may lodge. There being an aperture of exit is, therefore, no sure indica- * Guthrie, ed. ii. p. 19. f Clin.-Chir. Dupuytren, t. ii. p. 426. X Dupuytren, ibid. p. 428. § Obs. in Milit. Hosp. in Belgium, J. Thomson. GUNSHOT WOUNDS. 2S1 tion that one or more balls, or a portion of one, has not lodged; unless, in the latter case, the entire ball can be found. And, moreover, the number of exit-apertures are not necessarily the same as that of the balls which entered, or of the portions into which any one ball may have split. (e) Several openings, both of entrance and of exit, may be produced, and by a single ball. In one case, a ball passed through the hand, then the skm of the groin, and next the left buttock; thus causing six openings.* In another case, six openings also were caused by a single ball having passed through both thighs and the scrotum. (Guthrie.) Appearances of the Entrance and Exit Apertures respectively.—They are tolerably distinctive. (Fig. 45.) The aperture of entrance is a small, nearly circular opening, its margin inverted, slightly torn, and surrounded with an areola of purple ecchymosis. The aperture of exit, is larger and more irregular, its margin everted and more lacerated, shoAving the sub- cutaneous fat, and Avith less surrounding ecchymosis. These differential characters depend chiefly on the diminished velocity of the ball after its passage through the substance of a limb or the body. Consequently, the appearances of the entrance-opening vary somewhat in different cases, chiefly according to the speed of the ball; and its characters may re- Fig. 45. semble those of the exit-aperture. A larger penetrating body than a bullet, and one of an irregular form, as a small piece of shell, produces an opening similar to that of a bullet; but it is more lacerated and less circular, of small size also as compared Avith the fragment, this peculiarity resulting from the slanting direction in which it penetrates. Generally there is no exit-aperture ; such a projectile lodges, OAving to its compara- tively less momentum. A still larger penetrating body and of an irregular shape, as a larger fragment of shell, produces an aperture yet more lacerated, and of even smaller size as compared with the fragment. It also not unfrequently lodges. A large-sized projectile, as a cannon-ball, may penetrate and pass through the body, producing an entrance- and an exit-aperture, which * Hist. Cljir. du Siege d'Anvers, Hippolyte Larrey, 1833. 282 SPECIAL PATHOLOGY AND SURGERY. respectively resemble those caused by a smaller projectile, as a bullet ; only that the characters of either aperture are presented on a much larger scale. If, hoAvever, such a projectile as a cannon-ball strikes one of the extremities, it carries away the entire limb, as if transversely ampu- tated ; leaving a contused stump, purple and pulpified. The stump is less abruptly truncated and more lacerated, if the ball impinge Avith diminished velocity, as when bounding along the ground it strikes off a limb. In both these forms of cannon-shot injury, the ball impinges in a direct line. If a cannon-ball strikes the body in a slanting direction, thus brushing the surface, and especially if when moving with a greatly diminished velocity, it rolls over the part; in either case, the skin may not be broken, its elasticity apparently preserving that texture entire, and scarcely any discoloration marks the course of the ball. But the gravest subcutaneous disorganization of other textures is produced ; even to the pounding of muscles, Aressels, nerves, and bone, or of the viscera. Such internal lesions, unaccompanied by any corresponding external signs, were formerly known as " wind-contusions," and attributed by French authors, to the " vent de boulet." Hamorrhage of an arterial character, may attend a gunshot wound ; and sometimes proves fatal almost instantaneously. A gush of arterial blood is seen, and then and there a pallid corpse. Generally, however, the accompanying laceration secures the vessel, as already described (Chapter XIV.), and prevents the escape of any considerable quantity of blood, at the time of injury. Puncture by a spiculum of bone, occasionally, will cause primary haemorrhage ; but a bullet may pass between an artery and vein in contact, as the femoral vessels, Avithout opening either vessel; their elasticity apparently preserving them intact. The pain of a gunshot wound is worthy of notice as a symptom. In the first instance, it is either like the sharp stroke of a cane, or a dull heavy blow ; differences due, perhaps, to the degree of contusion. The pain may be referred to a part remote, more or less, from the seat of injury. This want of localization, coupled with the inconstant and in- definite character of the pain itself, evinces its inferior diagnostic value as a symptom, compared with the signs already described. For a short time after the injury, the sensibility of the part is numbed; pain suc- ceeding, and with increasing intensity as inflammation and tension super- vene. The symptoms connected with the penetration of particular parts— perchance the viscera—are specially significant, in virtue of the function of the part, which is thus injured ; but, not pertaining to the general pathology of gunshot wounds, they are here omitted. Causes ; or kinds of Projectiles in Gunshot Wounds, and the Effects of these Injuries.—The shape of projectiles used in warfare presents several varieties, the chief of which are—spherical, as cannon-balls, grape, musket-shot, and shell; cylindro-conoidal, as balls belonging to rifled cannon and rifled muskets; irregular, but generally bounded by linear and jagged edges, as fragments of shells and splinters. (Longmore.) Inpoint of size, projectiles vary from a rifle bullet to the largest sized cannon-ball or shell. The material and density of projectiles are less various ; being either lead, as the common bullet, glass, as some hand-grenades, or cast iron, as cannon-ball or shell and all other missiles. The momentum of a projectile is represented by its weight and velocity. The velocity of different kinds of projectiles varies considerably. Accord- GUNSHOT WOUNDS. 283 ing to a table published in 1851, the common musket-bullet moves at the rate of 850 miles per hour, the rifle-ball, of that date, at 1000, and the 241b. cannon ball at 1600 miles per hour. But the musket-ball then could not be depended on to hit an object beyond 80 yards, and the rifle not further than 200 to 250 yards; while the present Enfield rifle is sighted to 900 yards, and the short Enfield to 1100 yards. (Long- more.) The kind of motion imparted to different projectiles and thence their course through the air, is a difficult question, which can only be analysed and determined mathematically, and is in fact a very important branch of dynamics. Different kinds of motion have to be considered in combi- nation, and as resulting from the propulsive force, subject to the law of gravity. A ball discharged from the old smooth-bore musket, has a double motion; it revolves on its axis at a right angle to the line of flight. A ball discharged from a rifle-bored musket or rifle, has also a double motion, but of a different kind; it revolves on its axis in the line of flight. The angle at which a projectile strikes may be said to be accidental in many or most cases, and unconnected Avith the missile itself or its motion. Striking frequently at or nearly a right-angle; one kind of missile—the shell—exploding on the ground, scatters its fragments upAvards, and thus any such fragment will strike probably at an acute or obtuse angle. The penetrating power of a projectile is determined mainly by its shape and velocity. The cylindro-conoidal form is very penetrating, in virtue of its mechanical advantage as a wedge. Thus, supposing one of the old musket bullets to strike a limb—at eighty yards, and an Enfield rifle conical bullet of the same weight at eight hundred yards ; the rate of velocity being equal in either case, the injury from the latter shaped ball may be expected to be much greater than that from the former. (Long- more.) The influence of velocity is well known, and shown by the different effects of the same kind of missile according to its speed. A spent cannon-ball, rolling or bounding alon>; the ground—ricochet ting, may carry away a limb ; whereas the same ball at full speed Avould level a line of men. ■ But the former injury, occurring possibly when the cannon-ball is rolling along so sloAvly, as apparently to have no more force than a cricket-ball, shows also the influence of weight as an element of the momentum. Density is an important consideration respecting the power of penetration. For example, in the tAvo most perfect of modern English rifles, the Enfield and the Whitworth—the projectiles and charges being of the same weight—Avhen lead is used, the penetration at eight hundred yards is one-third greater from the Whitworth than the Enfield; but, if a less yielding material be used, as when lead is mixed with tin, its pene- tration is as 17 to 4, at eight hundred yards. (Longmore.) The kind of motion has certainly some relation to the penetrating power of any pro- jectile. If spinning, like a top, at a right angle to the line of flight, as a bullet discharged from the old smooth-bored musket; the projectile is easily turned aside from its course; Avhereas, the screw-motion of a ball, discharged from a rifle-bored tube, coinciding with the line of flight, is very penetrating. Lastly, the angle at which a projectile strikes, must affect its penetration. A right angle will be more effectual than an acute or obtuse angle ; the impinging body having a tendency to glance off in striking at the latter angle. Other bodies are sometimes associated with projectiles as indirectly causing wounds, additional, perhaps, to gunshot 284 SPECIAL PATHOLOGY AND SURGERY. injury. Such missiles may be stones, splinters of wood or bits of iron from gun-carriages, portions of clothing or coins, and fragments of bone from a wounded comrade. Having borrowed their motion from the projectile itself, of whatever kind—perhaps a ball already spent-any such body strikes Avith a proportionately diminished impetus, and Avith different degrees of effect under various circumstances affecting its own displacement, shape, and so forth. The effects of a gunshot wound locally, and constitutionally are quite analogous to those of a punctured wound, or of any contused and lacerated wound. Parts are damaged far beyond the apparent extent of injury. Thus, the textures are killed to a greater or less extent along the track of the Avound, and a corresponding tubular slough is eventually formed. Shock, rather than syncope from sudden haemorrhage, is the primary constitutional disturbance. This sloughing is more extensive and the shock more overAvhelming and prolonged, when caused by projectiles of modern design; their more deadly character being due to their greater power of penetration. Considerable importance has been attached to shock, in the sense of concussion of the whole body, by a heavy projectile, as a cannon-ball. But this can only occur when the velocity of any such projectile is so much reduced as to give time, in striking, to overcome the inertia of rest in the body. A cannon-ball at full speed may carry away a limb with- out knocking down the individual, who falls simply by the sudden shock of injury to the nervous system. Tetanus is of common occurrence. But its frequency has varied much in different campaigns, and under different climatic influences. In the Peninsular War, it was estimated to occur in about 1 case in every 200 wounded; in the Schleswig-Holstein War, 1 in about 350 cases. In the Crimea, tetanus appears to have been of rare occurrence. Alcock's estimate of 1 to every 79 wounded is too high. After naval engagements, the mortality has often been high. Sir G. Blane states that, after Rodney's action, out of 810 wounded 20 Avere attacked with tetanus, being 1 in 40. But sudden change from heat to cold is the most frequent cause of tetanus among the wounded. This was observed after the battles of MoskoAva, Bautzen, Dresden, Chilianwallah, and Ferozepore. The above statistics include the propor- tion of cases of tetanus arising from all kinds of wounds, besides gun- shot. Consequences.—The vital career of a gunshot wound, is analogous to a punctured wound, or of any contused and lacerated wound. Gangrenous inflammation invariably supervenes, perhaps extensively, along the track of the wound ; and thus textures which may not have been killed more immediately, die subsequently. The total result is represented by the slough which forms. About the fifth day of a gunshot wound, this slough begins to loosen from the margin of either aperture, if tAvo exist, and the line of demarcation between the living and dead tissues is clearly visible; about the tenth day, the slough or sloughs may be seen hanging out of the openings, and come away in the dressings. A tubular casting of slough had hitherto intervened between the living tissues surrounding the course of the wound and prevented its union by adhesion. Suppura- tive granulations supervene, and the Avound heals, or should heal, from Avithin outwards. Pending this process of reparation, tension is often extreme and extensive, and suppuration equally profuse and diffused. Secondary GUNSHOT WOUNDS. 285 haemorrhage is not an uncommon event. It occurs most frequently on the sixth day. (Baudens.) Arteries which did not bleed primarily, or which Avere only slightly grazed, may noAV burst forth. Such haemor- rhage, if not suddenly fatal, may be uncontrollable, from its depth or in a disorganized part, or ultimately fatal in an individual already reduced by suppurative discharge. An unextracted ball plays a singular part in the subsequent history of a gunshot wound. Constant suppuration, and exfoliation if the ball be lodged in bone, are events which might be expected. But the ball may move from its first lodgment, and travel to some distance, in a devious course, and ultimately find an exit or still remain in the body. Various functional disturbances arise during these peregrinations. Again, the ball may become encysted in dense fibro-cellular tissue, and then being stationary and isolated in a sac, it occasions little or no inconvenience. Or, a long canal-like cyst may form, in which the ball, although im- prisoned, moves freely up and down. Apart from this general vital history, a gunshot Avound extending into any internal organ, exhibits a series of phenomena peculiar to the particular organ implicated; and thence the completion of the vital history of this form of injury, as occurring in different parts of the body, belongs to Special Pathology. Prognosis.—The prognosis of Gunshot Wound is partly analogous to that of any other contused or lacerated wound. The kind of structural disorganization is important; as leading inevitably to sloughing and sup- puration. The presence of any foreign body in the wound has a similar influence. But the extent and the depth of a gunshot wound, will much affect the issue. The prognosis is specially unfavourable according to the number and functional importance of the parts injured, as complications of the wound. Injury to large blood-vessels, nerves, or an internal organ, are thus, severally, unfavourable conditions; and proportionately to the functional disturbances thence arising. Compound Fracture, and Com- pound Dislocation, are obviously most serious complications of gunshot injury. The subsequent course of the wound in its undergoing reparation by suppuratiAre granulations, is an eventually favourable ground of prognosis. Treatment.—Immediately after a gunshot wound, certain requirements demand instant attention, as to haemorrhage, position, and shock. 1. Arterial haemorrhage, Avhether in the form of a jetting stream or a rapid dripping of blood, must be arrested forthwith. Abundant venous haemorrhage is scarcely less perilous. If a limb be the seat of injury, a tourniquet should be applied, so as to command the main vessels. The same rule holds good when the limb is struck off, as by a cannon-ball; a tourniquet should be applied above the stump. In the absence of this instrument, a substitute may be readily made, by means of a stone about the size of an egg, rolled in the middle of a pocket-handkerchief and placed over the main artery; the ends of the handkerchief being drawn around the limb and secured in a knot, and then twisted up tightly with a piece of stick or the hilt of a SAVord passed under it. A compress and an elevated position of the limb, are more suitable when the haemorrhage is purely venous. The part may be covered Avith cold wet lint, as a soothing application. If the head or neck be wounded, haemorrhage, Avhether arterial or venous, must be arrested by pressure; and cold applied. 2. Attention to position is important. A limb should be laid in an 286 SPECIAL PATHOLOGY AND SURGERY. easy position; and fixed during the removal of the Avounded person to Hospital, in order to prevent any disturbance of the injured part from shaking or from spasmodic action of the muscles. This precaution will be the more necessary when compound fracture or dislocation complicates the injury. If the chest be shot through ; the patient should be laid on the injured side, and cold applied. If emphysema occur, or if air escape freely through the wound, a broad rib-roller should be applied. If the abdomen be wounded, the patient should be laid on the injured side ; or, if the Avound be central, on his back, with the knees drawn up over a pillow or knapsack. Any portion of protruding intestine or other viscera, must be gently cleansed with water and at once returned. 3. Shock, or sometimes hamorrhagic collapse, may be most perilous ; and brandy, wine, or other stimulant, must be administered to preserve life. Cold water may be given freely to allay the parching thirst Avhich speedily ensues from loss of blood. The subsequent indications of treatment comprise—the permanent arrest of haemorrhage.—Extraction of foreign bodies.—The manage- ment of inflammation, and sloughing; and—the conditions requiring amputation. 4. Haemorrhage.—The permanent arrest of haemorrhage may first demand attention. If arterial, the application of a double ligature to the wounded vessel may be necessary; the wound being sufficiently enlarged perhaps by an incision for this purpose. But it is seldom requisite to have recourse to ligature for primary haemorrhage after gunshot injury. When a limb is torn off, leaving a stump, the lacerated vessels soon cease to bleed. Venous haemorrhage must still be arrested by pressure, and elevation of the limb. Other indications for interference with the wound are best determined by examining the patient in the position, as nearly as it can be ascer- tained, in which he was relatively to the projectile that struck him. In any other posture, the apparent course of the ball in the body, and thence also the probable extent of injury or the parts implicated, would be modified by muscular action and by the various degrees of elastic retraction of the wounded textures. 5. Foreign bodies.—To detect any such substance, the finger is the best searcher or probe. In case of doubt or difficulty of examination as to the lodgment of a leaden bullet, Nelaton's probe offers the requisite facility and certainty of diagnosis. In the well-known instance of Garibaldi, it will be remembered that a ball was detected with this instrument by Nelaton, after search had been otherwise made, repeatedly in vain. Enlargement of the Entrance Aperture.—A slight incision is sometimes absolutely necessary for the removal of a bullet or other foreign body ; but the rule of practice which formerly prevailed of invariably enlarging the aperture by incision and to some considerable extent was an error; suggested by the false pathology of thus converting a supposed " poisoned " wound into a simple incised Avound, and of giving free vent to the noxious discharge. Any foreign body, of irregular shape,—e.g., a fragment of shell, more generally needs release to effect its dislodgment and extraction ; the circumstances in this case at once showing the necessity, and regulating the extent, of incision. But unless for an obvious purpose, the rule should be to avoid making any enlargement of a gunshot wound, any extension of the original injury. GUNSHOT WOUNDS. 287 Fig. 46.* To remove a bullet some form of bullet-extractor is generally requisite or advantageous. The most convenient form is here represented. (Fig. 46.) Any kind of forceps is somewhat objectionable, owing to the dilatation of the textures in using the instrument. A bullet lodged in bone is, perhaps, most readily extracted by an elevator, aided by gouging away any overhang- ing portion of bone. Any other foreign body, as a portion of clothing, which might be mis- taken for some natural texture, should be searched for with the finger and removed by manipulation rather than with forceps, which are apt to seize both indiscriminately. Examina- tion of the dress will probably show whether a portion was carried with the shot into the wound. It should, however, be remembered that any such fragment may haA^e been with- drawn in undressing the patient. Foreign bodies are eligible for removal, according to the patency of their situation, as their presence can then be ascertained with proportionate certainty; but the relation of surrounding parts Avill affect the safety of an operation for extraction. Thus, when situated beneath the skin, although per- haps at some, distance from the entrance-aper- ture ; a bullet is readily detected and removed by an incision, care being taken to steady the ball lest it slip away out of reach. On the other hand, when the foreign body is situated deeply, and possibly already out of reach ; its detection is less certain, unless a leaden bullet, by Nelaton's probe, and its extraction, in any case, by operation, is less safely accomplished. If, therefore, the body so placed, cannot be distinctly localized, or should it be inaccessible surgically, or both; the rule of practice suggested, is to abandon any further research, as well as any attempt at operative interference. This injunction becomes absolute in the case of a foreign body lodged in any internal organ. An ordinary gunshot wound, presenting one or two, possibly more, openings, with an intermediate line of texture about to slough, is a kind of lesion which requires little or no external dressing. The apertures may be protected from exposure to dirt by corresponding pieces of wet lint; but any restrictive dressings Avhich would preclude the escape of sloughs and the discharge of pus, are altogether at variance with the suggestions of pathology. An irregular and lacerated Avound, externally, as by a piece of shell, may need such dressings to readjust and retain the textures in position. 6. The accompanying inflammation and tension with severe pain, are perhaps best moderated by warm water fomentations; but the choice of Avarm or cold and evaporating applications, must be guided by experience and trial in each case, rather than by any pathological considera- * This bullet extractor was used most successfully in the Franco-German war. An American invention, adopted by Weiss. 288 SPECIAL PATHOLOGY AND SURGERY. tion at present known. Early and free incisions may be requisite to relieve tension and thence the accompanying constitutional disturbance, and to give free vent to matter Avhich otherAvise accumulating would burrow and disorganize the part. This relief of tension will also limit the sloughing. Subsequently, the process of healing by granulation and cica- trization, guides and regulates whatever slight assistance may then be necessary on behalf of reparation. Of the untoward events to which a gunshot wound, in general, is liable; secondary haemorrhage is one. It is especially apt to occur when the sloughs loosen and separate—about the fifth or sixth day. At that time, therefore, the application of a tourniquet around the limb, in readi- ness to be tightened at a moment's notice, Avill always be a judicious precaution, but only as a temporary measure to arrest the haemorrhage. Ligature of the bleeding vessel or vessels is imperative, and without delay. This should be done in situ, if possible; or Avhen impracticable, then by ligaturing the main trunk ; or that failing to command the haemorrhage, amputation is the only resource. The probability of gangrene superven- ing, and thence the propriety of amputation; and the question whether it should be primary or secondary, are subject to the same or analogous considerations as with regard to contused and lacerated wound, and to compound fracture or dislocation. 7. Amputation.—The following conditions are said to require ampu- tation ; and with destruction of the whole substance of a limb, there can be no question as to the propriety of primary amputation :—: (1) If the limb be completely crushed and disorganized, whether by a direct blow or by wind contusion, though still left adherent; or, if the principal vessels and soft parts be carried away, though the bone be uninjured ; or when the whole limb is carried off, a ragged stump merely being left. (2) In some of the more serious injuries of the lower extremity, amputation is especially necessary. Thus, if a bullet divide the femoral vessels, or the sciatic nerve, and splinter the thigh bone ; or if the sciatic nerve and soft parts at the back of the thigh be carried, away, although the vessels and bone be left uninjured ; and generally, all compound fractures of the lower part of the thigh. Amputation of the upper two- thirds of the thigh, for gunshot injury, is generally fatal. On the other hand, such injuries rarely recover. Six cases, however, and in the upper third, are reported to have occurred during the Crimean war. (Long- more.) (3) Gunshot fracture of the bones of the leg, if the tibial arteries be injured, or if the knee or ankle-joint be wounded. In the middle of the leg, and if there be no longitudinal Assuring of the bone into either joint; the removal of splinters of bone may suffice. (4) Gunshot wound of the foot, extending into the tarsus, requires amputation at or above the ankle; Avhile analogous injury of the hand, often allows some operation of partial removal, reparation being more active in the hand than in the foot. Thus, three or four fingers with, perhaps, their metacarpal bones may be amputated, and a remnant-hand or thumb-hook be preserved. (5) In gunshot injuries of joints; those of the upper extremity do not generally demand primary amputation ; those of the lower extremity are more urgent. If the head, neck, or trochanters of the femur be splintered into the articulation by a bullet wound; death Avith or Avithout MORBID CICATRICES. 281) amputation, at the hip-joint, is about equally inevitable. Excision— as also in some cases of compound dislocation—is a more safe com- promise. Bullet Avound of the knee-joint, is a case for amputation rather than excision ; but a similar Avound of the ankle-joint, is, more frequently, an appropriate condition for excision. Bullet wound of the shoulder or elbow-joints, are conditions in relation to which excision is, yet more fre- quently, a promising substitute for amputation. Thus, 13 out of 14 cases of excision of the shoulder were successful in the hands of M. Baudens. Of 12 cases of excision of the shoulder-joint, 2 were fatal; in 17 of the elbow- joint, 2 only were fatal; and in 5 partial excisions of this joint, all were suc- cessful. Such, according to Mr. Thornton, were the results in the British Army during the Crimean War. In the Russian Army, according to Messrs. Mouat and Wyatt's Report, of 20 elbow-joint excisions, 15 recovered. In duly considering whether amputation should be primary, or secondary—to give the limb its chance; the large proportion of un- favourable or fatal results of secondary amputation, must ever be taken into account. During the siege of Sebastopol, there were 3000 amputa- tions, among 80,000 wounded Russians. Of the primary amputations of the upper extremity, of the lower and middle third of the thigh, of the leg, and foot, about one-third recovered ; but of all the secondary ampu- tations, more than two-thirds died. These results are more than corro- borated by those in previous wars. Thus, primary amputation was successful in three-fourths of the cases, under Larrey, during the Napo- leonic Wars; whereas, of 300 secondary amputations, reported by Faure, after the battle of Fontenoy, 30 only Avere successful. In the' Peninsular War, the loss after secondary amputations of the upper extremity, was, as compared with the primary, as 12 to 1; and of the lower extremity, the loss was three times as great. The general treatment—hygienic and medicinal—in relation to gun- shot wounds, is the same as, under similar circumstances, Avith regard to other contused or lacerated Wounds, Compound Fracture, and Disloca- tion. Hygienic measures are chiefly important, and they claim special attention in Military Camp Hospitals; where, OAving to the contingencies of warfare, regimen, ventilation, and general cleanliness, are more than usually liable to be defective. CHAPTER XVII. MORBID CICATRICES. Morbid Cicatrices are either failures of reparation in the healing of Wounds, or various conditions of its results—in the form of faulty cica- trices. They comprise :—(1) Deficient cicatrix ; (2) Excessive cicatrix; (3) Painful cicatrix; (4) Ulceration, Growths, and Degenerations of Cicatrix. (1) Deficient cicatrix.—A thin, flat, shining, reddish, easily wrinkled and cracked scar, remains, commonly, after the imperfect healing of a Aveak ulcer or scrofulous sore. Such a condition depends obviously on deficient reparative poAver of cicatrization. Treatment.—Pencilling with nitrate of silver, sulphate of copper, or other stimulant application, and protection of the surface from any ex- ternal occasion of inflammation or injury ; constitute the most probably u 290 SPECIAL PATHOLOGY AND SURGERY. successful topical treatment. Any causative constitutional condition may be less preventable or remediable. (2) Excessive, and exuberant or Cheloid cicatrix.—An opposite condi- tion to the preceding ; this form of cicatrix is thick, more or less project- ing, irregular, dense, and perhaps adherent. Contraction of such a cicatrix is not an uncommon character, and the force thus exerted may be so powerful and long continued, as to produce great displacement and deformity. This result usually folloAvs cicatrization after a burn, par- ticularly if it be deep and extensive. (See Figs. 47 and 48.) Cheloid or exuberant cicatrix, is well defined, gradually rising, Avith a rounded border, and a smooth, level, or slightly convex, or sometimes centrally depressed surface. Its substance is always tough and firm, becoming more so as it grows older. At first, usually more vascular than even a recent healthy scar, and having a florid or purple tint; it gradually becomes paler as it becomes harder, and at length resembles healthy exuberant skin. In point of structure there is nothing peculiar; compact fibro-cellular tissue more or less completely developed or degene- rate, and slightly vascular, is covered with a thin cuticle. The size of a cheloid groAvth is generally distinctive; rarely more than half an inch in thickness, or more than half an inch in any direction beyond the extent of scar in AA'hich it grows, the growth thus differs from a fibrous growth of skin Avhich it nearly resembles. Exuberant cicatrix may arise from some local cause of irritation during cicatrization, or some more obscure cause of a constitutional character. The latter would appear to be the origin of cheloid cicatrix; considering its infrequency as compared Avith the frequency of wounds and scars, and that many such growths may appear in the same individual, and reappear in the scars of Avounds made for their removal. Cheloid cicatrix may supervene on a completely formed healthy cicatrix, and even long after it has remained so; it groAvs slowly, and generally, after a long duration ceases to enlarge or diminishes, and it is liable to undergo degeneration and ulceration. Treatment.—Strong stimulants, applied repeatedly, have some effect in dispersing an excessive cicatrix; apparently by inducing or favouring degeneration and disintegration of the already imperfectly developed fibro- cellular tissue, and thus facilitating its absorption. Further growth may at least be retarded or prevented in like manner. Iodine paint and mer- curial ointments, will perhaps prove the most effectual of these appli- cations. Adhesion of the cicatrix to subjacent textures and to bone, is best overcome by subcutaneous division, as was, I believe, originallv recommended by Mr. Hancock. A cicatrix, hitherto intractable, will, Avhen thus detached, contract, and not unfrequently close in rapidly. Contraction of the cicatrix—as after a burn—is more preventable than curable. Mechanical restraint by some form of contrivance adapted to the situation and extent of the ulcer, and applied as soon as the eschar is detached, will perhaps prevent the effects of contraction. Counter-ex- tension, by similar means, in the direction of contraction, will less surely overcome its effects. But it may be necessary to continue such resis- tance for weeks or months; often taxing the ingenuity of the Surgeon, and trying both his perseverance and that of his patient. In accordance with pathology, the general principles to be observed are the following :__ That scar-tissues seem rather to adapt themselves by changes of nutrition to the external forces brought to bear on them, than to be merely stretched by them; that, in hoAvever long a time, the natural course and tendency MORBID CICATRICES. 291 of scars is to soften down to a greater resemblance to the natural parts in both structure and relations; and, that they are of low vital poAver, apt, therefore, to waste or ulcerate quickly under irritation, friction, or pressure, and are thus removable by absorption. Cheloid cicatrix is removable only by excision, complete extirpation being necessary, and not even then a guarantee of non-recurrence; but a recurrent growth of this kind is not more intractable than the original one. Plastic operations, planned according to the particular case, are available for the cure either of excessive or of cheloid cicatrix. The chief general rules for such operations may be thus stated:—That if the scar is to be removed, so as to bring healthy structures together for union in its place, no portion whatever of its substance should be left; that scar-tissues should not be used for the formation of flaps, or relied on for any speedy or sound union ; that if the scar or part of it is to be included in any flap for sliding or transplanting, all the borders and surfaces of such flap intended for union should, if possible, be of healthy structure, and not themselves parts of the scar ; and, that flaps should not be depen- dent on scar-tissues for their supplies of blood. (3) Painful cicatrix.—Commonly arising from adhesion of the sub- jacent nerves to the skin or bone, and not attributable to bulbous en- largement of their cut extremities; the cicatrix of any wound may thus be painful, although most frequently that of a stump after amputation. Usually, the cicatrix-tissue is sound, but the nerves are subject to constant irritation or inflammation, varying with the mobility and movement of the part. Neuralgic pain, of an excruciating and paroxysmal character, is due rather to some constitutional cause affecting a'cicatrix, still healthy in itself. This condition may supervene long after the cicatrix is com- pletely formed, and has loosened from any subjacent adhesions in the natural course of healing. Treatment.—Free subcutaneous section is almost sure to prove re- medial, when the pain arises from adhesion of the cicatrix. It is readily accomplished by introducing a tenotomy knife from the centre of the cicatrix, which usually remains open as an intractable ulcer, and sweeping round the cicatrix, to beyond its circumference. In this way I lately succeeded in permanently curing a painful cicatrix over the projecting head of the astragalus, after Chopart's operation. I found it necessary, however, to remove a portion of the bone, in order to bring the margins of the ulcer together, and to divide the tendo-Achillis in order to prevent retraction of the stump and tilting forAvard of the astragalus as was the case before the operation. The result was, that the pain ceased and the ulcer healed over the stump, the tendon was permanently lengthened by gradual extension of the foot after operation, and the man walked well on the flat of the stump to the ground. This result Avas the more noteworthy and satisfactory, considering that, as a crucial experiment, I had previously divided the tendo-Achillis Avithout any effect on the cicatrix. Neuralgic pain can only be cured, if at all, by constitutional treatment; chiefly by quinine, and careful regulation of the boAvels. The topical application of aconitina -will often temporarily allay this pain ; a grain of the best preparation of the alkaloid to a drachm of lard, in the form of an ointment applied from time to time. (4) Ulceration, and other morbid changes, growths and degenerations, affecting cicatrix-tissues, folloAv the same pathological laws as in other structures; and are amenable to the same treatment, accordingly. u 2 292 SPECIAL PATHOLOGY AND SURGERY. CHAPTER XVIII. BURNS AND SCALDS. LIGHTNING. FROST-BITE. Burns and Scalds.—Structural conditions, and Diagnostic characters.— Formerly, burns were classified according to their different degrees of structural disorganization, as represented by, inflammation, suppuration, sloughing, and ulceration. Fabricius Hildanus, Boyer, and Dr. J. Thomson, observed only three degrees of disorganization; Heister and Callisen recognised a fourth; but Dupuytren* was dissatisfied with this ground of classification, which regarded only the intensity of the burns, while the nature of the parts affected—the textures injured or destroyed— Avere altogether disregarded. He therefore superadded this kind of classification, by distinguishing burns according to their various degrees of depth, from the surface inwards to deeper parts. Firstly.—Erythema, or simple reddening of the skin. Secondly.— Vesication, the cuticle being raised in blebs, filled with serum. Thirdly. —Incomplete destruction of the skin. Fourthly.—Complete destruction of the skin, extending down to and involving the subcutaneous cellular texture. Fifthly.—Conversion into eschars of muscles, nerves, vessels, and other soft-tissues to within a variable distance from the bone. Sixthly.—Charring and complete disorganization of the whole substance of the burnt part. Obviously, this classification recognises not only the various degrees of disorganization, beginning with erythema and ending with charring ; but the various kinds of tissue—i.e., anatomical differences —are also recognised as grounds of distinction. Thus may be enumerated, burns of the skin, and those involving the cellular texture, the muscles, nerves, vessels, and so forth. The distinctions laid down by Dupuytren are, hoAvever, practically useless. Deep burns, to the fourth, fifth, and sixth degrees, extending successively through tissues having very different anatomical characters, are not attended with correspondingly different degrees of shock, they undergo the same process of reparation by sloughing and suppurative granulation, and with equal probability of recovery. It should also be observed that, as the textures successively destroyed by deep burns serve very different functions in the animal economy, the relative im- portance of such burns is not proportionate to the physiological character and importance of the parts destroyed. Nor again, is the Surgeon con- cerned with the pathologico-anatomical differences of burns. He estimates not the effects of heat on the body by observing the different degrees of disorganization produced in the various textures—that this eschar is yellow and hard, and that is black and brittle—as the geologist or minera- logist would examine specimens of igneous rocks. The insignificance of pathologico-anatomical differences—no less than those derived from anatomy and physiology—will become more clear, and the basis of the most exact and early diagnostic distinctions of burns be supplied, by observ- ing, clinically, the functional disturbances pertaining to them, or their * Lecons Orales tie Clin.-Chir., 1832, torn. i. p. 423. BURNS AND SCALDS. 293 pathology. These lesions, indeed, afford an almost exceptional instance of the superior importance of this ground of diagnosis, as compared with that of clinical pathological anatomy—by virtue of physical and structural characters. [P. ch. ii.] Superficial burns are most important, and in proportion to the extent of surface affected, but not necessarily destroyed structurally. The more superficial the burn, the more the skin alone is affected, if only exten- sively ; the more urgent will be the constitutional disturbance, and the more dangerous is the burn. A negro employed at the Bains Vigier, in Paris, wishing on one occasion to warm his limbs, which were benumbed with cold during a rigorous winter, immersed himself in a bath heated to a high temperature. In a short time he experienced a general feeling of uneasiness Avith acute pain in the skin. He was immediately withdrawn and carried to the Hotel Dieu, where he expired in thirty-six hours! It is reasonable to suppose in this case, that although the water was heated to a high temperature, yet it was not at the boiling point, and that it acted only as a general rubefacient, without raising or destroying the cuticle; and yet here was a burn of only the first degree, but very extensive, and therefore accompanied Avith a shock to the nervous system, so sudden and overwhelming as soon to have proved fatal. Deep burns, when not superficially extensive, are of comparatively subordinate importance; their significance having reference generally to the remote consequences of such burns, namely, exhaustion by sloughing and suppurative discharge. Causes, and their effects locally and constitutionally.—Heat applied to the body is necessarily the cause in all cases; but it may have been either by fire, as by the clothes catching fire, the explosion of gunpowder or other explosive compound; or by means of a hot or scalding fluid, as boiling water or molten lead. The lesions produced in the former way are commonly designated burns ; in the latter way scalds. This distinc- tion is of practical consequence; burns not unfrequently resulting from the more prolonged application of heat, are deeper lesions, but perhaps of less superficial extent; scalds resulting from the more momentary application of heat, are more superficial, but generally they affect a larger extent of surface. Any adhesive fluid, as boiling oil, is a more persistent cause, and boiling perhaps at a higher temperature than water, it affects the tissues to a greater depth, as well as superficially. Some such fluids, clinging to the surface, run over a yet greater extent. Thus, then, scalds may be even more severe than burns; both by the duration of the cause, and the extent of lesion, superficially and in depth. Explosive compounds are destructive, not only as causing burns of considerable extent, but also by the mechanical violence of their ex- plosion, producing Avounds which might be called burnt wounds, contused or lacerated. . Grains of gunpowder, grit, mud, or other material, may, moreover, be introduced as foreign bodies into such wounds. Wounds of this kind Avere Avell marked in the persons of the unfortunate victims of the " Clerkenwell Explosion," admitted under my care into the Royal Free Hospital. In all cases, the wounds Avere not only contused or lacerated, and ingrained with dirt, as if portions of flesh had been gouged out by extremely forcible splashes of mud; but the surface of these wounds and surrounding integument, Avere apparently burnt, and con- tused by the concussive atmospheric force of the explosion. All the Avounds sloughed for some tune, Avith a yelloAv, and freely suppurating 294 SPECIAL PATHOLOGY AND SURGERY. surface ; liealing very slowly by granulation. The cicatrix subsequently contracted, and assumed a seamed, puckered appearance, notably in the Avounds of the neck ; just like the cicatrix presented by the healing of a burn. Burns and scalds immediately induce pain and shock, both of which are more or less severe according to the superficial extent of lesion. The symptoms of shock, affecting the nervous system and circulation, are the same as those arising from any other injury. But it is accompanied Avith congestion of internal organs; the brain, lungs, and mucous membrane of the gastro-intestinal canal. The duration of collapse is variable, averaging about 48 hours—two days. Course and Terminations.—(1) Shock, or Congestion, proves fatal in many cases within the first two days; and indeed of all the fatal cases of burn, a great majority die in this period. Mr. Erichsen collected 50 fatal cases, and Mr. T. Holmes 75 such cases, of burn; the former, with a view of determining the organs most frequently affected in each degree and period; the latter, with the special view of determining the mode and cause of death. 35 out of the whole 125 cases, died on the first or second day; but as the great majority of those who are thus burnt to death are not examined, the proportion is much greater than this. Thus, of 119 other cases brought to St. George's Hospital, 79 died in this period. In 16—Erichsen's proportion—of the 35 cases, the brain and its mem- branes were found congested, with more or less serous effusion into the ventricles or arachnoid, in 15 cases. The brain in the other case was not examined. In the remaining 19 cases, the brain was examined only in a few, but in 1 only was it healthy in respect of structure and vascularity. The thoracic viscera were congested in 8 of the 16 cases, and in 6 of the 19 cases; the congestion having passed into demonstrable inflammation in 1 of the former, and in 3 of the latter; thus making thoracic conges- tion in one-half the cases examined. The abdominal organs were some- what less frequently congested; in 12 of the 16 cases, in 3 only of the 19. The mucous membrane of the pharynx and larynx, is extremely liable to be congested, apparently owing to the inhalation of flame or heated air during the accident; of the 19 cases collected by Mr. Holmes, which died in the first two days, some appearance of this kind was found in 13. The congestion in the pharynx very generally ceases abruptly at the commencement of the oesophagus; in some rare cases passing down into the stomach. (2) Reaction and Inflammation constitute the next, or second period ; extending from the end of the second day to the end of the second week. During this period, 25 out of the 50 cases died ; and 29 out of the 15 cases ; or 54 out of 125. The brain, lungs, and intestines, are the viscera prin- cipally affected ; laryngeal cases usually die earlier. In the 25 cases, the brain was affected in 14 ; 11 being simple congestion, and .3 serous effu- sion. Of the 29 cases, the brain was not examined in the great majority; but in 3 it was congested, with effusion into the ventricles or arachnoid; but there was no evidence of true inflammation in any case. The lungs are more frequently affected. In the 25 cases, these organs were con- gested in 10 cases, and inflamed in 5. Of the 29 cases, inflammation of the lungs or pleura had occurred in 7 (in one of which, however, it probably existed before the accident), and congestion was noted in 5 others. The abdominal viscera—liver, spleen or kidneys—are perhaps never affected as a consequence of burns, except by pyaemia. But the BURNS AND SCALDS. 295 mucous membrane of the gastro-intestiual canal, is usually inflamed, and probably ulcerated ; with, in some cases, evidence of peritonitis. Inflam- mation followed by ulceration of the duodenum, is a notable occurrence, in the second period of burn, to which Mr. Curling first drew attention. In the 25 cases, ulceration of this portion of intestine was found in 6; in the 29 cases, in 4 of them ; making a total of 12 such cases out of 54. In 3 more of the latter series, enlarged glands were found, in 1 of which cases, the glands of the whole intestinal tract Avere enlarged. The duodenal ulcer is sharp-edged, and tolerably circular, as if a portion of the mucous membrane had been cut out; it is perfectly indo- lent, and usually situated just below the pylorus. Often there are two or three close together. Generally, the burn is on some part of the chest or abdomen. The earliest known period of duodenal ulceration is the fourth day; on the fifth day, it was noticed in 2 cases, and in 1 on the sixth. It usually occurs about the tenth day. This ulceration is unac- companied by general inflammatory symptoms, or by any special symp- toms. Persistent vomiting and bloody diarrhoea are the most reliable. Perforation of the bowel may ensue, and death take place suddenly from haemorrhage, or from acute peritonitis. In one case, however, after death from other causes, at the end of eight weeks, a recent cicatrix was found in the duodenum. (3) Suppuration and Exhaustion, or Inflammation, still prevailing, represent the third period ; extending from the end of the second Aveek to the termination of the case. The proportion of deaths at this period, Avas 9 in the 50 cases—less than 4, and 27 in the 75 cases—more than \. Brain-lesions are accidental, being limited to infantile convulsions and pyaemia. The lungs or pleurae are far more frequently congested or inflamed, and this condition is the cause of death. Thus, in 6 out of 9 cases examined in Mr. Erichsen's table—lesions of the lungs and pleurae were noted. In 4 of these, the appearances Avere distinctly inflammatory; in the other two there was congestion with effusion into the pleurae. Out of 27 of Mr. Holmes' fatal cases—during this period—the lungs were affected in 10, in 8 of which inflammation was the principal cause of death. Here, generally, the burn is situated on the chest. The symptoms— physical examination being precluded—are sufficiently marked; pain and oppression of breathing, hacking cough, and bloody expectoration. The gastro-intestinal mucous membrane is less frequently congested or inflamed; but ulceration of the duodenum is still not uncommon. Out of the 27 fatal cases referred to, in 6, open ulcers were found in the duodenum; in 1, a similar ulcer had undergone cicatrization, and in 1, the Avhole mucous membrane of the small intestines was inflamed but not ulcerated. In the other 9 cases referred to, no ulceration of the intestines Avas discovered. In 1 case only of Mr. Holmes' series, the jejunum and ileum Avere ulcerated, the duodenum being intact. Reparation.—Burns and scalds undergo the same process of repara- tion, as similar lesions otherwise caused. But some features in their career are peculiar. Erythema, produced by a burn or scald, tends to subside, like any other simple cutaneous inflammation; resolution taking place Avith desquamation of the cuticle. Vesication also is resolved and terminates in like manner. Deeper burns involving, successively, the skin, subcellular tissue, and other adjacent textures; are folloAved by sloughing with the formation of eschars, abundant suppuration, and then the healing process of granulation and cicatrization. But the granula- 296 SPECIAL PATHOLOGY AND SURGERY. tions are exuberant, and the cicatrix contractile. At first thin, of a purplish colour, and shining, stretched, appearance ; it immediately begins to contract, and contraction continuing for some months, with great and increasing force, the cicatrix gradually assumes a seamed and puckered Fig. 47. appearance; drawing together the surrounding parts, and ultimately pro- ducing strange deformity. Thus, remarkable distortions of the face and neck (Fig. 47), or of the joints are produced (Fig. 48). Fig. 48. Tetanus, pyaemia, erysipelas, and other affections may be omitted in estimating the causes of death as from burn ; they being, rather, accidental concomitants. The period of death, varies. The most fatal period is, perhaps, the BURNS AND SCALDS. 297 first week after the accident. Erichsen found that in 50 fatal cases, 33 terminated before the eighth day; 27 of these dying before the fourth day. Of the remaining 17 cases; 8 died in the second week, 2 in the third, 2 in the fourth, 4 in the fifth, and 1 in the sixth week. Prognosis.—The chief considerations which determine the prognosis of burns and scalds, are—the more or less superficial character of the lesion and its extent, its situation, duration of the cause, and the age of the patient. The first tAvo of these indications were sufficiently noticed in connexion with diagnosis; a superficial but extensive burn is far more un- favourable than a deeper and limited one. Hence many scalds are more fatal than burns. These indications, however, have reference to death principally by shock or congestion, in the first period, after burn; or by reaction and inflammation, in the second period. The depth of a burn— as compared with a scald—is significant with reference to suppuration and exhaustion, terminating fatally, in the third period. Deep burns are also unpropitious with regard to the part affected; distortion and loss of function supervening. The situation of a burn, more especially indicates the probability of visceral congestion. Thus, burns on the chest or abdomen, are especially dangerous in relation to congestion of the lungs, or gastro-intestinal mucous membrane, respectively. Burns of the scalp are not so ominous of cere- bral congestion ; but they are specially unfavourable as regards the liability to erysipelas. The duration of the burning cause is, perhaps, favour- able, as to the less liability of internal congestion or inflammation ensuing, but unfavourable so far as it implies a considerable depth of burn and consequent exhaustive discharge. Age has scarcely any relation specially to the prognosis of burns. Children are peculiarly liable to the danger of (secondary) visceral affections, cerebral, thoracic, and abdominal; and more easily succumb to their influence than adults. Extreme age is, of course, always comparatively unable to resist the shock, and conse- quences of injury. Treatment.—(1) Shock and the tendency to Congestion, require imme diate attention. Wine, brandy, ammonia, are the stimulants commonly administered to induce reaction. Warm tea may be sufficient, if* the patient be young and the burn slight. Laudanum, in favour with some Surgeons, is, I think, undesirable, as being conducive to congestion. (2.) Re- action, occasionally excessive, must be moderated by any gentle depletory measures, otherAvise than by loss of blood. Mild purgatives and the with- drawal of stimulants for a time, will generally reduce any undue reaction, as measured by the pulse and heat of the skin. It should ever be remem- bered that any temporary tendency to inflammatory symptoms, readily subsides into a congestive tendency, affecting the internal organs. (3.) Sup- puration and exhaustion, are specially inevitable in the course of deeper burns ; although some exhaustion supervenes in all burns. The strength of the circulation should therefore be retained for this period; and main- tained when it arrives. Stimulants are again required, Avith tonics, and the generous diet suitable in cases of profuse and prolonged suppurative discharge arising from any cause. Local treatment.—The primary indication is, protection of the surface from exposure to the action of the air. Increased and persistent pain and shock will thus be prevented. Various topical applications are used pro- tectively, and sometimes indiscriminately. The degree or depth of burn, will, I think, best determine the choice. 298 SPECIAL PATHOLOGY AND SURGERY. Erythema, or vesication, cannot require any application more than simply protective. " Carron-oil," consisting of equal parts of linseed oil and lime water, ansAvers admirably. Lint, dipped in this thick, yelloAv, pul- taceous fluid, forms a covering, at once exclusive of atmospheric influence and emollient. Deeper burns, destroying the cuticle, skin, and so forth, thus presenting an exuding surface, are perhaps more adA'antageously covered with some absorbent material. Flour, dredged over the surface soon forms an encrusting artificial skin. This need not be removed until loosened by increasing discharge and separation of the eschar. The removal of this crust by the Surgeon would be attended with great pain, and damage to the surface about to heal, and would aggravate the constitutional disturbance. But, the possibly irritating character of this kind of dressing, and the impossibility of removing it, without these evil consequences, are serious objections to any such application. Cotton-wadding wrapped around the part forms a good protective covering, and aids in restoring the tem- perature of the part, a consideration of importance in proportion to the extent of surface involved; but this application alone is objectionable for the same reasons as the flour-dressing. Carron-oil dressing, enclosed it may be with cotton-wool, is, generally, the most eligible application. The ulcer formed by the detachment of the eschar, must be treated agreeably to the general directions already given with regard to Ulcers. Water-dressing, or a weak solution of nitrate of silver, will then be appro- priate, according to the state of the granulations. Pencilling the marginal granulations with nitrate of silver or sulphate of copper, may be necessary, to repress their exuberant growth, and favour cicatrization. No dressing in the whole course of treatment, should be reapplied unnecessarily; its removal being attended with great pain, and much increasing the consti- tutional disturbance. One of my earliest recollections as a student, was that of witnessing the shrieking of a patient during the dressing of a large burn over the thorax and abdomen, the muscles quivering and bleating by exposure to the air. Contraction of the Cicatrix is the grand difficulty to be prevented or overcome. In anticipation of this event, Dupuytren recommended attention to position and the application of counteracting mechanical con- trivances, as soon as the eschar had become detached and during cicatri- zation. But any such adjustment of splints and bandages or other apparatus, will generally prove effectual only for a time; the cicatrix contracting when left free, and at length presenting- its usual appearance and the accompanying deformities. Operations, therefore, are practised with the view of overcoming con- traction. Division of the cicatrix has often been tried, but with little permanent success. Complete division is necessary, both as regards the extent and depth of the cicatrix, any subjacent bridles must also be freely divided. All contraction having been thus overcome, extension should be maintained mechanically during granulation and cicatrization in the lines of incision. With every precaution, however, the new intervening cicatrix-tissue is apt to acquire the same evil disposition. I have had recourse to this operation in many cases, and repeatedly in the same case; but with no more successful results than in the hands of other surgeons. Transplantation of a flap of healthy skin into the gap made by division and extension of the cicatrix. This proceeding is far more generally successful, permanently. Very happy results have been attained by Teale, Mutter, and James in thus overcoming the deformity occasioned LIGHTNING. 299 by burns of the face and neck. Eversion of the lower lip into the chin, a disfigurement attended with slobbering peculiarly revolting, may be remedied by Teale's operation. The everted lip is divided into three equal parts, by two vertical incisions, each three-quarters of an inch in length, and carried down to the bone. These incisions are so placed that the middle or intervening portion occupies one-half of the lip. From the lower end of either incision, another is carried upwards to a point one inch above the angle of the mouth. The two flaps, thus indicated, are freely and deeply dissected up. The alveolar margin of the median portion is then pared. The lateral flaps are raised, united by twisted sutures in the middle line, and supported as on a base by the median flap, to which they are also attached by a few points of suture, leaving a triangular even surface to granulate. Gradual extension of the cicatrix from the sternum, and eleAration of the chin can be accomplished by means of a screw collar devised by Mr. James. Diseased conditions of the cicatrix have received sufficient attention in this work among Morbid Cicatrices, in general. Erichsen notices par- ticularly a projecting red and glazed cicatrix, looking as if composed of a mass of fungating granulations smoothed down and lightly skinned over. This Avarty cicatrix—observable after burns about the neck and chest, more especially—resembles cheloid groAvth, but is remarkable as being the seat of intolerable itching, not relieved by any external applica- tion. Large doses of liquor potassae mitigate this distressing symptom. But, if small and narrow, the cicatrix may be dissected out; if large, it does not admit of removal without risk of considerable haemorrhage, as the structure, though fibroid, is very vascular. Amputation is an operative resource unavoidable in certain external cases. Complete destruction, by charring, of the whole substance of a limb, leaves no alternative; or, as a secondary operation, it may become advisable under circumstances, locally and constitutionally, analogous to those resulting from other forms of injury. Lightning .produces effects, locally, in the direction of its course through the parts, resembling the appearances of an ordinary burn ; but the shock may suspend the functions of the nervous system, partially or generally, without any marked appearances of burn, and may thus also kill instantaneously. A stroke of lightning affecting the brain, knocks down the individual with loss of consciousness ; lasting from a few minutes to a longer period, in one case an hour and a quarter. Recovery shows that paralysis Avas suddenly produced, partially or completely; and this state may continue for an indefinite period. The special senses are variously affected; loss of sight, smell, hearing, and taste; or more rarely, exaltation or per- version of these functions may have occurred. Haemorrhage from the mouth, nose, or ears, sometimes happens ; and abortion in some cases. A remarkable effect is said to be produced occasionally; the formation of an image, as if photographic, of neighbouring objects on the body, even on parts covered with clothes. Every degree of burn may be produced, and perhaps in the same person, from the slightest singeing of the hair, reddening or blistering of the skin, to the deepest charring. Other incidental injuries may occur, but rarely, such as Avound, or fracture, particularly of the skull. The tongue was mutilated in four out of six cases of injury recorded by M. Bondin. 300 SPECIAL PATHOLOGY AND SURGERY. The prognosis, partly guided by the same considerations as with regard to Burns, is generally more favourable respecting the local lesion, Avhich may be comparatively trivial, and also in respect to shock. But the subsequent paralysis or other functional disturbance may be a specially unfavourable condition, as consequent on a stroke of lightning not immediately fatal. Some persons seem to have premonitory symptoms of the approach of a thunderstorm. One such individual, within my own knowledge—a remarkably robust young man—is invariably troubled with extreme nervousness, headache, and an indescribable dread, com- pelling him to go to bed some hours before any apparent approach of a storm. How far this might be an unfavourable state of the nervous system is unknown. After death by lightning, certain appearances are remarkable if not characteristic. The attitude of the body may be that in which it was when struck, or the body may be throAvn to some distance from the spot. Rigor mortis, occasionally absent, is commonly present, and well marked, or even to an intense degree of rigidity, resembling the condition of a person frozen to death. The blood, sometimes coagulated, is usually singularly fluid, and continues in this state. Decomposition is sometimes speedy, but often delayed. The clothes are generally burnt or rent, even Avhen the body is intact. The Treatment of suspended animation from a stroke of lightning con- sists in artificial respiration, with warmth and stimulants to restore the circulation. Frost-bite. — Cold, intense or long continued, produces effects analogous to those of heat. It may kill the part directly, a local destruction analogous to charring, and accompanied Avith depression of the nervous and vascular systems, analogous to shock ; or the part dies by the speedy supervention of gangrenous inflammation, a process of destruction accompanied Avith inflammatory reaction as the constitutional disturbance. Unlike heat, cold more frequently kills by its direct operation; presenting the condition knoAvn as frost-bite. This local effect, moreover, frequently exceeds in importance the concomitant general depression of the system. The local condition may therefore be taken first in order. The symptoms are—loss of sensation and poAver of motion in a muscular part; and, the circulation becoming arrested, a remarkable pallor overspreads the surface, deadening into a stone colour, with stiffness increasing to hardness, and even brittleness of the part, when quite dead. The constitutional disturbance arises principally from general exposure of the body to cold, under the circumstances of frost-bite. Languor, and an overpowering sleepiness, ending in stupor or coma, invariably super- vene during prolonged exposure to severe cold, and may thus cause death, the part itself dying with the general failure of life. The whole body becomes frozen by more continued exposure, and thence the condition known as " frozen to death»" A part frozen or frost-bitten is not irrecoverably dead. A whole limb may have become perfectly insensible and cold as ice, white and transparent like marble, incapable of being bent Avithout breaking; and yet not absolutely dead. The combs of cocks and the ears of rabbits were frozen by Hunter, but these parts afterAvards recovered. Leeches and frogs have been placed in the same state and then restored to life. Cold- blooded animals, and parts of warm-blooded animals, Avhen frozen, are, CELLULITIS, CARBUNCLE, AND BOIL. 301 therefore, not dead, but asleep as it were, and can be aroused ; even as a seed is ready to sprout, awaiting circumstances favourable to life. How long a frozen part or animal may retain its susceptibility of life is uncertain; but this is certain, that unless reaction be gradual, the returning flow of blood is apt to become excessive—to pass into inflamma- tion, speedily ending in gangrene. While, therefore, gradual and moderate elevation of temperature induces salutary reaction and restoration, sudden or immoderate accession of warmth will inevitably excite gangrenous in- flammation. Treatment.—In the dormant state of any part of the body from frost- bite, Avhen although apparently dead the part is recoverable, pathology suggests the solicitation of reaction short of inflammation ; and thence the prevention of gangrene with loss of the part. Restorative reaction can only be accomplished by the moderate and gradual application of warmth. Friction with something of nearly the same temperature as the frozen part, fulfils this tAvo-fold indication ; and thus, rubbing the part with snow is a practice both surgical as well as popular. A tingling or burning pain, and purplish redness, announce the returning circulation and tendencjr to inflammation. Gangrene having supervened, the separation of the slough should be left to Nature; any unnecessary interference would give a fresh start to the process of destruction, in textures reduced to a low state of vitality. Amputation may become necessary, as after a burn; the operation being performed also in point of time and situation, after the formation of the line of demarcation and above it. CHAPTER XIX. cellulitis, carbuncle, and boil. Certain Blood diseases are declared by local inflammations of the sub- cutaneous cellular texture. Cellulitis.—Structural Condition.—The textural changes wrought by this inflammation are these:—Speedily an effusion of serum engorges the subcutaneous tissue; this being soon exchanged for a purulent, bloody, sanious fluid. The cellular membrane dies rapidly, appearing in the form of shreds and skeins, and as mats of wet tow, or like large wads of wet shammy-leather ; extending over a whole arm, a whole side, or over both, successively. An immense extent, therefore, of cellular texture is sacrificed, and this wide-spread subcutaneous slough passes in between the neighbouring muscles; but the fasciae are singularly spared; thus the tendinous septae betAveen the ribs are seen bared in places where the muscular substance itself and all other textures have disappeared. This process of destruction probably involves the skin, and to a corresponding extent. Yet Aresicles or bullae seldom appear until the subcutaneous inflammation is very far advanced. These vesicles are in general solitary, sometimes remote from the cellular disease, of considerable size, and occasionally filled Avith bloody serum Symptoms, and Diagnosis.—Cellulitis might be mistaken for erysipelas. The swelling is not unlike,—in both diffuse and oedematous. But the pain is at once the earliest and most distinctive symptom; it is excru- 302 SPECIAL PATHOLOGY AND SURGERY. ciating. This, without perhaps any, even the slightest blush of redness, is characteristic of cellulitis. And should the skin become involved, the cutaneous inflammation is ahvays secondary, in all cases of true cellulitis; by advance from below upwards, from the cellular texture to the skin. This latter texture remains uninflamed, or is not primarily and essentially affected. Fever.—The fever which precedes and accompanies cellulitis, aids but little to establish an early and exact diagnosis. In those cases which Duncan observed, this fever had so much of the typhoid type, that it was scarcely possible to foresee which disease would be eventually declared. Nevertheless, the fever presented considerable varieties in respect of its symptoms and progress. It sometimes commenced insidiously, sometimes turbulently, but in most of the severe cases soon reached its height. Its chief peculiarities were ; the supine position with depressed shoulders, in which attitude the patient almost always lay, without turning to either side, the absence of coma, and the rare occurrence of delirium. The respiration was often remarkably embarrassed, owing to the inspiratory muscles,—pectorals, intercostals, &c, being the seat of cellulitis. In some cases, dyspnoea was rendered more urgent by pleurisy. In others, the respiration was itself much affected, especially when the disease began in the arm. Certain facts of apparently minor significance, because only occasional, are; a peculiar cadaverous smell emitted from the patient's body during life; in one case, a foetid and coloured sweat proved critical. Blood origin.—Two facts at least point to the inference that cellulitis is the local manifestation of a blood-poison. The fever being typhoid, resembles the working of some blood-poison analogous to that which is undoubtedly in operation when typhoid fever is engendered by "infection;" and the local manifestation itself—cellulitis being a "serpiginous" inflammation—extending continuously, and not confined to one spot, shows that some morbid condition of the blood disturbs the course of textural assimilation. Blood-pathology.—The nature of the blood-poison is wholly unknown. The best account of this disease is given by Dr. Duncan.* Treatment.—Preventive measures are unknown, nor can they be dis- covered until the etiology of this disease is better understood. The remedial treatment, so far as art has any controlling influence, is sub- stantially the same, both constitutionally and locally, as for phlegmonous erysipelas. Carbuncle and Boil are alike, essentially, inflammations of the sub- cutaneous cellular texture, which may occur in various parts of the body; but the effusion is circumscribed and brawny, so that the imprisoned cellular tissue invariably sloughs. Certain differences are worthy of notice. Carbuncle or Anthrax is a flat, oval or circular, somewhat spongy swelling, having a brawny circumscribed border; the whole swelling being of a dusky, reddish-brown colour, and very painful,—burning, con- tracting or throbbing. The size of this swelling varies from half-a-crown to that of a dinner-plate, and it varies also with the progress of the inflammation. Increasing slowly, at length the skin over the flat surface, sloughs at numerous points, forming as many small apertures, through which a greyish sloughy and purulent, foetid discharge oozes, or starts * Trans. Med.-Chir. Soc. Edin., 1824, vol. i. CARBUNCLE OR ANTHRAX. 303 up on the slightest circumferential pressure; presenting a cribriform appearance never to be forgotten when once seen, peculiar to carbuncle. As sloughing of the skin advances, the apertures run together and coalesce, the cribriform surface disappears, and discloses the subjacent cellular texture, a quagmire of slough. Carbuncle is commonly situated about the shoulders or on the nape of the neck, where if large it gives a remark- able breadth to that part. Occasionally occurring on the lower part of the back or sacrum, it may form on the front of the chest or abdomen, sometimes on either extremity, and very rarely on the forehead or face. One on the nose, seen by Sir B. Brodie, gave the most singularly hideous appearance, completely disguising any lineaments of the human face. Fortunately, carbuncle is usually solitary. Fever of the typhoid character precedes and accompanies the swelling, and it becomes more marked as sloughing ensues. But there is also a notable derangement of the liver and other digestive organs, indicated by a yellowish complexion and brown furred tongue. The causes of carbuncle are, as to their essential or pathological nature, obscure. It is a disease of advanced years, or it occurs in those whose constitution has broken down prematurely. It is also induced by habitual free living, without exercise. It is associated, not unfrequently with diabetes mellitus or albuminuria; and swellings of a carbuncular character are not uncommon in some infectious diseases, as typhus and typhoid fevers, and plague. Course and Terminations.—Generally, the slough of cellular texture having been thrown off or removed, the cavity, often of considerable size, slowly heals by suppurative granulation; and the patient's health is ultimately regained, a marked improvement having taken place when the slough was detached. But the brawny induration remains for some time, and a puckered cicatrix permanently. Sometimes, however, the sloughing deepens as well as extending superficially; and involving important subjacent parts, or overwhelming with prostration, thus proves fatal. A large carbuncle situated on the nape of the neck is especially perilous. Rarely, a carbuncle subsides suddenly, and the person rapidly sinks. A remarkable instance of this mode of fatal issue, is related by Sir B. Brodie.* The prognosis, in different cases, will be guided by the foregoing considerations. Treatment.—Preventive measures are said to be occasionally successful. In the earliest stage of the disease locally, while yet only " a small pointed vesicle on a hard, braAvny base," observes Mr. Erichsen, its further progress may often be completely arrested by opening the vesicle and rubbing its interior Avith a pointed stick of potassa cum calce or nitrate of silver. Later still, he has often seen the extension of a carbuncle pre- vented and a cure effected, by covering it with a square of soap-plaster spread on thick leather, Avith a hole in the centre for the exit of discharge. I have had no experience of a carbuncle in this stage, nor of the preventive treatment accordingly. Curative Treatment consists chiefly in a certain operative proceeding. The preservation of as much integument as possible, by the limitation of sloughing, with the relief of pain and con- stitutional disturbance, are primarily important; and the discharge of slouch subsequently is equally so. Early relief of tension fulfils the * Pathology and Surgery, 1846, p. 393. 304 SPECIAL PATHOLOGY AND SURGERY. former indications, an outlet fulfils the latter. Timely, free incisions, fulfil both. A ci'ucial incision, carried through the slough and the surrounding induration, answers admirably. The period for making this double incision, must be determined by due observance of both the purposes in view; always inclining to the consideration of relieving tension. A free application of potassa fusa, after the bistoury, was recommended by the late Professor Miller, in order to at once form an eschar and thus limit sloughing. Poulticing until the slough is discharged, and then dressing according to the state of the ulcer, are the only applica- tions ordinarily required. The constitutional treatment, medicinal and dietetic, much resembles that of phlegmonous erysipelas. Early recourse to stimulants, tonics, and a generous diet; but with special attention to the state of the liver and digestive organs. Yet here we encounter the chief difficulties. In- appetency, nausea or actual sickness, and mal-assimilation, all conspire to defeat our alterative mercurials and effervescing salines, as well as our endeavours to coax the stomach with digestible and nourishing food. If any other disease, to wit, diabetes or albuminuria, be associated with carbuncle, such complication will further embarrass the treatment. Boil or Furunculus.—In some of its external characters, Boil con- trasts with Carbuncle. It is a conical SAvelling, softening as it maturates, but set in a hard base ; of a purplish red colour, and exquisitely painful and sensitive. Its size is much more moderate than carbuncle, never perhaps exceeding the smallest swelling of that kind, about half-a-crown. Its smaller size and conical shape are diagnostic, even in an early stage. Enlarging slowly, matter forms at the apex of the cone, tipping it with a yellow colour; this point bursting, at length discloses a subjacent slough or core of cellular texture. But, the cribriform, flat, surface of carbuncle is never seen,—another diagnostic difference. Like carbuncle, a boil is commonly situated where the skin is thickest; on the back of the neck, shoulders, or the buttock, a favourite spot of election; occasionally in the arm-pit, or on the thigh. They always seem to choose the most troublesome situations. To increase the torment, they seldom come singly, but are gregarious or successive. Feverishness, generally of a more sthenic character than with car- buncle, accompanies the formation of boils. The causes also, so far as they are knoAvn, somewhat differ from those of carbuncle. Usually occurring in earlier life, boils are also connected with a plethoric state of the system; but they may denote an enfeebled condition, or they may appear in the sequel of febrile diseases. Their fitful character is often far less explicable. Active exercise by persons of sedentary habits, sea-bathing, the spring-time of the year, or some epidemic influence, will, perhaps, severally suffice to bring out a crop of boils. The treatment is that of carbuncle on a small scale. A poultice or warm fomentation, to promote suppuration and detachment of the slough, should be followed, if the latter does not take place, by a sufficient incision for expulsion of the core without any thumbing or squeezing. With water-dressing, the little granulating wound will then look after itself. Constitutional measures must have reference either to the plethoric or debilitated state of the system. Alterative mercurials and saline aperients, followed by liquor potassae and other alkaline treatment; or quina, iron, and nitro-muriatic acid, the acid-tonic treatment. WHITLOW OR PARONYCHIA. 305 Chilblain.—This is a local inflammation of the skin, of an asthenic type ; and subject, perhaps, to regular recurring attacks of congestion. It occurs in three degrees:—(1) Simple congestion, attended by great itch- ing, alternating with periods of extreme tenderness to external pressure; (2) or, in the form of vesication; (3) death or sloughing of the affected portion of skin, and perhaps of the sub-cellular tissue, forming an ulcer of an indolent character. The Symptoms of chilblain are obvious, in connexion with each of these forms of this affection. Congestive purplish-redness, with a tingling, itching, or burning heat or pain, which comes and goes, and some degree of swelling which has a shiny appearance. Recurrence of the symptoms seems to be determined by circumstances affecting the circulation, as ex- posure of the part to the warmth of a fire, or of a periodic character, as the stimulant effects of daily meals. The vesicated and ulcerated forms of chilblain present appearances which are sufficiently indicated by these terms. Certain parts of the body are most commonly affected; the feet, hands, or both; more rarely, the lobes of the ears, or even the end of the nose. The causes of this affection may be said to be, sudden variations in the external temperature, and in connexion with the predisposing con- dition of a weak circulation. Hence, chilblain is liable to occur in persons of the leucophlegmatic temperament, or of a scrofulous consti- tution. Age has decidedly some influence ; it happens most frequently in young persons or children, and of both sexes ; and in adult females more often than in men. This liability generally passes off towards manhood ; and chilblains are rarely met with in men over forty years of age, though in weakly women they may recur throughout life. Local causes affecting the free circulation in the part, should not be overlooked; such as tight gloves, elastic bracelets and garters, tight shoes, the sitting posture, long continued, in cold rooms, with the legs pendant. Treatment.—Preventive measures will consist in promoting the general circulation ; by an even temperature, particularly as regards sleeping and sitting rooms in cold weather, warm under-clothing, socks and gloves, with regular exercise; and, the removal of any restraint to the circulation in exposed parts of the body. A generous diet, with small stimulant doses of opium and quinine, may likewise prove salutary. In the event of any chill, affecting particularly the feet and hands, the circulation should be restored \rery gradually, by frictions and warmth. Curative treatment consists, when chilblains are unbroken, in bringing the congestive inflam- mation to resolution, by daily frictions with stimulating embrocations, as of camphor or tincture of iodine, and soap liniment. The old-fashioned remedy, brandy and salt, should not be despised. Intolerable itching might, perhaps, be relieved by lead-lotion, or opiate ointments. Vesicated chilblains may be protected by a coating of collodion and castor-oil varnish. Ulcerated chilblain must be treated by poulticing rendered stimulating by admixture with spirits of Avine, or turpentine, until any slou'di separates ; and then the dressing may be resin-ointment, or other topical applications, as for any other weak or indolent ulcer. Whitlow or Paronychia.—An asthenic inflammation of the dense fibro-cellular tissue forming the pulp of the finger or thumb ; this part becomes acutely painful, tense and hard, swollen so as to give a globular appearance to the end of the finger, and of a reddish colour (Fig. 49). The inflammation and swelling are always diffuse—unlike phlegmon ; and x 306 SPECIAL PATHOLOGY AND SURGERY. it tends also to suppuration and sloughing of the cellular texture,—thus also differing in its termination. Necrosis of the ungual phalanx is not an uncommon event, in prolonged cases. Whitlow occurs spontaneously in persons of a naturally weak or of a debilitated constitution, affecting both young and old, and either sex. Occasionally, it Fig. 49. appears to have an epidemic character, arising in many persons without any traumatic cause; and perhaps at certain seasons, as in the spring. But it arises frequently from some local irritation, as a puncture, scratch, or inoculation with some poisonous matter. Hence, it is more frequently met with in connexion with certain occupations, as in cooks, washerwomen, and grooms. Whitlow, involving the sheath of the tendons, is a more severe form of this affection. It is at- tended with greater swelling of the whole finger, extending to the hand, which becomes much puffed and enlarged. Shooting pain up the arm, and more violent throbbing with suppuration, are ex- perienced ; but the redness is not proportionate, and the end of the finger, particularly if the cuti- cle be thick, and the palm of the hand hardened by work, may assume a dull-white appearance—soddened, perhaps, by poulticing. Some inflammation of the lymphatics, denoted by red lines extending up the arm, not unfrequently accompanies this form of whitlow, and with much low feverishness or constitutional dis- turbance. Diffuse suppuration soon takes place in the sheath of the tendons, and may even spread up the fore-arm, under the annular ligament. The swelling has an elastic character, but distinct fluctuation is obscure. Sloughing ensues, not only of the cellular texture of the finger and hand, but also of the tendons and palmar fascia. Necrosis of the phalanges results ; or a matted state of the part, with a rigid and contracted state of the finger and perhaps of the hand, rendering the part useless. Treatment is primarily, the prompt employment of repressive mea- sures ; by leeching, poulticing, and an elevated position of the hand. In the simple form of whitlow, a crucial incision into the pointed swelling of the pulp of the finger, should be made at an early period; or even snipping the vesicated summit will give great relief. In the tendinous form of whitlow, early, and free, longitudinal incisions, along each side of the finger, must be had recourse to, for the relief of tension and swelling. The digital arteries should be avoided, and the sheaths of the tendons not opened,—to prevent sloughing, and rigidity of the finger ensuing. Then well soak the finger, and hand, in warm water, and envelope the whole with a poultice. The nail, which growing and elongating, may appear large, often loosens, and should then be removed by evulsion with a small pair of sequestrum-forceps. Otherwise, as a foreign body, it would be a source of continued irritation. Any adherent portion need not be removed, but the remainder of the nail may be pared and scraped. A new nail will form, if the matrix be healthy; probably taking a period of five or six months, before it is completely restored. In tendinous whit- low, when the inflammation has subsided, a pasteboard splint will be advisable, to prevent contraction. ONYCHIA. 307 Necrosis of the ungual phalanx will necessitate the extraction of this dead portion of bone ; leaving the pulp end of the finger and nail, which eventually form a somewhat hooked extremity, tolerably sensitive and useful, and not so unsightly as a truncated end. Amputation will be unavoidable, in the event of more extensive destruction, involving the middle, or the first, phalanx. And it is better to operate rather, ap- parently, too high, than too low for the sake of preserving a useless rem- nant of a finger ; any portion of the thumb, however, will be most useful. The general health must be renovated by tonics and diet. Onychia is a form of ulceration, which commences about the matrix of the finger-nails It usually arises from a pinch or crush of the finger end, bruising the matrix or loosening the attachment of the nail. Shortly after this injury, the finger-end swells, and fluid is effused beneath the nail, Avhich loses its natural colour, and becomes thin and flattened at the end, or more rarely curled up laterally. As the nail continues to grow, it turns upward and exposes beneath it, a very foul, foetid, and painful ulcer; Avhile the finger-end becomes enlarged and bulbous, the integu- ment hardened, shining, and of a livid red colour. This affection occurs mostly, according to Mr. Thomas Smith's observations, in children under ten years of age ; but that it is by no means common. It is little prone to spon- taneous recovery ; proceeding, perhaps, to necrosis of the ungual phalanx. The disease is sometimes named onychia maligna, as a specific ulceration. Treatment is firstly, evulsion of the nail; and this is accomplished either by tearing it off as a whole by seizing it with a narrow- bladed pair of sequestrum-forceps ; or, by dividing the nail with a narrow-bladed pair of scissors, run up to the root of the nail, and then everting each half with the forceps. Both scissors and forceps must be applied with a firm hand. Local anaesthesia will suffice to completely deaden sensibility—the pain otherwise being excruciating. Pounded ice and salt mixed in a bladder is convenient for this purpose, or Dr. Richardson's ether spray is equally efficacious. Water-dressing or carbolic lotion may then be followed by arsenical solution—one or two drachms of the liquor potassae arsenicalis, to an ounce of Avater. Chlorate of potash and tonics, especially bark, complete the treatment. Syphilitic onychia, as a secondary affection, has already been noticed. In-groavn Toe-nail.— This is a not uncommon condition, among especially the Avorking-classes; it may occur on either side of the great-toe nail, but more frequently on the outer side. It is attended with con- siderable pain in walking, and gives rise to fungoid and sensitive granulations, overspreading and concealing the in-growth, accompanied Avith a thin, foetid discharge. This condition is caused apparently, either by overcrowding the toes in a narrow, hard boot, thereby thrusting the adj dining integuments over the side of the nail; or, by the toe-nail having been pared aAvay too deeply at the side, thus allowing the integument to overlap; in either way the nail grows into and includes itself in the over- hanging fold of integument. Treatment consists in removing any cause of pressure, as a tight, or hard-toed boot, and then endeavouring to correct a faulty groAvth of the nail. The pressure of the integument on the nail may also be relieved by neatly inserting shreds of oiled cotton-wool into the cleft by means of a probe on the back of a scalpel-blade. Then, when sufficiently separated in the course of some days, the margin of the nail may be gradually raised in like manner, until the natural state of the part is restored. Scraping the edge of the nail very thin may prove to be x 2 308 SPECIAL PATHOLOGY AND SURGERY. sufficient relief; or, by notching the free edge down to the matrix, the strip of nail as it grows, may gradually overlap the body of the nail, and thus bring relief. Any obstinate or deep in-growth can only be cured by evulsion of the nail, as in the treatment of onychia. After any such mode of cure, the fungoid granulations will subside, or they may be repressed by pencilling with nitrate of silver or sulphate of copper. Zinc ointment may be applied during the healing. Corns.—Local hypertrophy of the cuticle forms the common corn ; a flattened or conical swelling, hard or soft, often acutely painful—varying in this respect, according to pressure on the part, the state of the health, and even the weather. Such cuticular out-growths occur commonly on the feet, usually on the outer aspect of the end of the little toe ; or between the toes, and then always as a soft corn, apparently from maceration of the cuticle by warmth and moisture. Occasionally, corns form on the hands, and more rarely over the prominences of the elbows or knees. They are produced by intermittent pressure or friction on some naturally prominent part, as on the little toe, by wearing a tight, hard boot. Eventually, beneath an old corn, a bursa is apt to form, which, becoming inflamed from time to time by pressure, greatly aggravates the pain and inconvenience in walking. Suppuration is liable to occur. Treatment.—Relief is obtained by simply removing the cause of pressure. Wearing a loose shoe or slipper, or protecting the corn by means of a circular plaster of thick leather, having a hole in the centre over the corn. Thus, the common " corn-plasters " are used. Pencilling with nitrate of silver induces desquamation, and thus thins down the corn. Paring or scraping down the corn previously macerated in warm water, will also give relief, as occasion requires. Extraction of the centre or core of the corn, is the ordinary practice of chiropodists. But the full-grown corn is liable to return. Inflammation and suppuration must be treated on ordinary principles. Horns.—Remarkable forms of out-growth, consisting of fibrous or fibro-cellular texture, are liable to occur on various parts of the body; springing from the various sebaceous cysts, unruptured, or ruptured spontaneously or by accident. Similar kinds of out-growth may arise from the matrix of one of the toe-nails, especially the great toe; extend- ing from one to four inches in length, tapering at the point, and curved spirally like a ram's horn. This is simply a vertical elevation of the epithelial layers forming the nail. Excision completely from the base of the horn is the only cure. Warts or Verruca are collections of overgroAvn cutaneous papillae, either completely ensheathed by an excessive production of scaly epithelium, or with the papillae isolated, each having only its own natural cuticular sheath. They may occur in various parts of the body, a common situa- tion being the hand and fingers. Warts may arise spontaneously, apparently, or be congenital, or perhaps hereditary; but usually they proceed from some source of local irritation—as dirt or discharge, or from the handling of animal matter, in cooking or dissection. They occur in girls who have the evil habit of masturbation, though the presence of warts on the hands should not alone beget an unworthy suspicion of such practice. Venereal warts, excrescences, or vegetations, well illustrate the origin of warty growths from irritative discharge. Such and similar warts are undoubtedly contagious. Common warts come and go, sometimes, in an unaccountable manner. RUPTURE OF MUSCLE AND TENDON. 309 treatment.—Escharotics may succeed in removing these often obstinate out-groAvths. The strong acetic acid, applied by means of a glass-brush, or rod, is the most efficacious. Excision with the knife or curved scissors, is the only other mode of cure. Morbid Growths.—Besides Warts and the other cutaneous out- groAvths already referred to, the skin may be the seat of tumours or morbid growths—e.g., painful subcutaneous tubercle, naevus, epithelial cancer. (See Ch. II.) Ulcers. (See Ch. IV.) MUSCLES AND TENDONS. CHAPTER XX. SPRAIN.--RUPTURE.--TUMOURS. Sprains or Strains.—Structural Condition, and Symptoms.—Muscular and tendinous structures are liable to be suddenly stretched by violence, Avithout any actual or perceptible rupture of fibre. This lesion commonly occurs to those muscles which are most apt to be brought into action by any sudden and violent exertion, as in running, leaping, dancing, or lifting a weight. Immediate pain and inability to use the part, followed by stiffness, are conclusive symptoms. Any degenerative change, or soften- ing of the structure, will predispose to this kind of injury. It may be succeeded by atrophy and partial paralysis. Treatment.—Rest is necessary for reparation, and this requisite is secured by the renewal of pain from any attempt to use the damaged muscle or tendon. Subsequently, friction and stimulant embrocations aid in overcoming the stiffness and remoA'ing any remaining thickening. Rupture of Muscle and Tendon.—This lesion may be regarded as only a further degree of sprain, but it presents certain additional particulars of importance. The part of the muscle or tendon ruptured is in the muscular sub- stance, the junction of the muscle and tendon, the tendon, or the junction of the tendon and bone. In twenty-one cases Sedillot found the rupture had occurred at the junction of the muscle and tendon in thirteen, but through the muscle in eight only. Occasionally, the sheath of the muscle or tendon is ruptured ; a protrusion taking place through the aperture. This more frequently occurs to the long head of the biceps muscle, or the extensor tendons of the fingers. The muscles most liable to sprain are also subject to rupture, by sudden and violent exertion. Hence the gastrocnemius, or its tendon; the quadriceps femoris, just above the patella, of Avhich I have seen tAvo instances—the biceps and triceps of the arm ; the former giving way above, in its long head, or beloAV, at its in- sertion, the latter muscle or tendon rupturing just above its insertion into the olecranon. More rarely, the deltoid or the pectoral muscle yields, the rectus abdominis, or the muscles of the back. The symptoms are generally well marked; sudden pain and powerless- ness, Avith a sensation as if something had given way, and perhaps an 310 SPECIAL PATHOLOGY AND SURGERY. audible snap. Pain is far less acute if a tendon be ruptured. An interval may be discovered in the situation of rupture, into which the finger will fall when passed over the surface ; a hard swelling above and below is also felt—the retracted muscle, if its substance be the seat of rupture. Sub- sequently, this state of the part is obscured as inflammatory swelling supervenes, or reparative lymph occupies the interval between the ruptured ends of muscle or tendon. Some discoloration may accompany the former change, or any extravasation of blood incident to the injury. Causes.—Muscular contraction is the immediate cause of rupture far more frequently than external violence. Age predisposes, by reducing the elasticity of muscular texture in common with that of all textures. Rup- ture, therefore, occurs most frequently in persons of middle life, and who are sometimes wont to undertake feats of sudden exertion beyond their strength, in running, jumping, dancing, or lifting a weight. Degenerative changes will also predispose; and thus the rectus abdominis muscle has been found to have undergone fatty degeneration in some cases of its rupture. I am not aware of any such predisposing conditions having been noticed in connexion with the rupture of tendons. Course, and Terminations.—(1) Reparation ensues, and readily, in most cases. It has been traced by Paget and Adams in rabbits, and by the latter observer in the human subject. The process is the same, essen- tially, and alike after subcutaneous division or rupture, as follows :— Separation of the ruptured extremities of a tendon,—e.g. tendo- Achillis, takes place to a very variable extent; in an adult, from one to two inches, in an infant, about half an inch. The upper portion is drawn upwards, proportionately to the contractile power and con- traction of the muscle, and the lower portion is drawn downwards, proportionately to the mobility of the ankle-joint and position of the foot. Similar or analogous circumstances limit the separation of the divided extremities of tendon in all cases. The separated ends still remain indirectly connected with each other through the medium of the cellular sheath of the tendon, which remains almost intact, as a tubular sheath. Blood, in very small quantity, is generally effused within the sheath, and adheres to the upper and lower extremity of the tendon, principally to the upper. But if the blood be sufficient to fill the sheath and infiltrate the surrounding tissues, reparation is retarded, and rendered proportionately less perfect. It is an un- favourable incident. Increased vascularity of the sheath marks the commencement of the true reparative process; this vascularity extending to the subcutaneous cellular tissue and fat. Reparative blastema is effused into the meshes of the cellular sheath, as a matrix, which thus becomes succulent, as well as vascular; the infiltration may also extend into the surrounding cellular texture, and obscure the gap in the divided tendon. This blastema is developed into fibres, through the medium of oval nuclei; unlike inflammatory lymph in open wounds, which is developed into fibres through nucleated cells, transition forms being found in the shape of elongated cell-fibres. The nucleated blastema would seem to undergo transition by elongation of the oval nuclei, and their arrangement in parallel linear series; thus presenting a fibrillated, and ultimately more distinctly fibrous appearance, under the microscope. Capillary blood- vessels are formed in the connective tissue thus produced, and concurrently Avith the process of its development. RUPTURE OF MUSCLE AND TENDON. 311 The divided ends of the old tendon take no active part whatever in the reparative process during its earlier stage, and have but slight con- nexion with the new material when first formed. A little later, their square surfaces and sharp edges become somewhat rounded, and their substance somewhat softened. Enlarging, and evincing a disposition to split; thin streaks of new material, greyish and translucent, are inter- posed ; indicating the commencement of junction between the old and new tissues. The bulbous enlargement of the old tendon-ends, occasioned by the increasing interposition of new material, gradually subsides; until they regain their former appearance, and the new and old tendon become of uniform diameter. The appearance of fine dovetailing long remains, being distinctly traceable a year and a half, and three years, after division of the tendon. Complete and firm junction of the new Avith the old tendon is established; a want of definition along the deep surface of the new tendon, remaining permanently, owing to adhesion between this surface of the tendon and the deep fascia. Re-formation of a separable sheath on the surface of the new tendon, completes the pro- cess of reparation. The new tendon, homogeneous rather than fibrous in appearance, is at first vascular and ruddy, but afterwards greyish and translucent; an appearance contrasting with the old tendon, above and below, and which is retained up to the latest period of examination hitherto made in the human subject, or three years after operation. Considerable toughness and strength is soon acquired; in the tendo-Achillis of a rabbit, six days after its division, a weight of 20 lbs. was required to rupture it, and after the lapse of ten days, the rupturing weight had increased to 56 lbs. A linear cicatrix is supposed by Mr. Tam- plin, and other observers, to be the ulti- mate remnant of the bond of union; but, according to Mr. Adams' observations, this appearance is deceptive, the connective tissue or new tendon remaining perma- nently, during life. The greatest length of new tendon formed in the human sub- ject, is apparently, as Mr. Adams states, two inches and a quarter ; and this was found in the tendo-Achillis of a girl, aged nine years, a year and a half after teno- tomy. Divided muscles undergo, essentially, the same process of reparation, union by a fibro-cellular bond. Treatment.—Rest is of course requisite for union to take place; but attention to position by relaxation of the muscle or tendon, and the maintenance of that posi- tion, are equally necessary, the structure being not merely strained or stretched, but divided. These indications of treatment are well illustrated by the treatment of rupture of the tendo-Achillis. The leg is flexed, and the heel drawn up, by means of a band attached to the shoe behind, and Fig. 50. 312 SPECIAL PATHOLOGY AND SURGERY. fastened to a belt around the lower part of the thigh. (Fig. 50.) If the relaxed position be disregarded, the uniting bond will inevitably be elongated and weak. With this result, antagonistic muscles may afterwards occasion considerable deformity by their continued and inadequately opposed contraction. Talipes varus—after operation and premature removal of the splint—may thus become slowly converted into the opposite deformity,—talipes valgus. Hence also the newly united muscle or tendon should be exercised very gradually and cautiously. (2) Imperfect and non-union of Tendon.—Various causes lead to these results. Imperfect union of the tendo-Achillis, for example, may arise from, some constitutional defect in the reparative powers of the individual, or from depressed vital power in the limb, owing to paralysis. Injudicious after-treatment, from ;—not sustaining the temperature of the limb, especially in paralytic cases during Arery cold weather ; too early and too rapid mechanical extension ; too early exercise of the part. A^icw-union is specially liable to arise, when tendons are situated in dense tubular sheaths; the divided ends of tendon becoming adherent to the inner surface of the sheath, but not having any direct connexion with each other. Treatment.—Any of the causes of imperfect, or non-union, must be avoided or corrected. With respect to mechanical extension, after opera- tions for deformity; Mr. Adams does not consider it necessary to make extension gradually, for the purpose of stretching the new tendon, the requisite length of which should be obtained during the period occupied in its formation, ordinarily, tAvo or three weeks ; but gradual extension is necessary, either to overcome ligamentous resistance, or to prevent a too rapid and excessive separation of the divided ends, and thus regulate the length of new tendon produced. The liability to non-union may be avoided, by never dividing a tendon in its course through the denser portions of its sheath, and when the operation is performed near to such parts, extension should be conducted very gradually. Certain operations have been practised to induce the reparation of an ununited tendon. Paring the ends and joining them by suture will seldom prove satisfactory. Subcutaneous puncture, as for ununited fracture, has proved successful in some cases. Displacement of Tendon may occur. The tendon of the tibialis posticus muscle, occasionally slips out of its groove, with instant pain and lameness. The long tendon of the biceps flexor cubiti is sometimes tilted out of its groove. Such mishaps generally rectify themselves, the tendon slipping in again ; or replacement can be readily accomplished by a little manipulation. Inflammation of Muscle.—Rare as a primary disease, the muscles may be involved by the extension of Inflammation from adjacent structures. Rheumatic inflammation of the muscles is probably of this kind, affecting primarily the investing aponeuroses. Syphilitic inflammatory indura- tions of muscle are also said to occur. A notable instance of inflammatory extension I once saw ; peritonitis extending to inflammation of the abdominal recti muscles, which after death presented a quagmire of slough and pus. Immediately behind the sheath of these muscles, and near the umbilicus, lay the vermiform ap- pendix of the caecum, which contained a bean. It was, apparently, a grand effort of Nature to discharge this impacted foreign body. BURSiE MUCOSAE. SYNOVIAL BURS.E. 313 The treatment of muscular inflammation must be conducted on general principles, having reference to the apparent causes in operation. Tumours of Muscle—Equally rare, perhaps, as primary diseases, the muscles are yet sometimes the seat of Morbid Growths. The reader is referred to the distribution of Morbid Growths, for some such particu- lars. But, Mr. Teevan has collected 62 cases of tumours of muscles. About one-third were cancerous; 16 fibrous ; 8 cystic; 5 hydatid; and 5 erectile. Mr. Erichsen has seen 7 cases of tumours " primarily " formed in muscles. In 1 case, a fibro-cystic tumour, as large as a cocoa-nut, was " developed in connexion with the tensor vaginae muscle;" in 1 case, a cystic tumour, the size of a foetal head, developed in the substance of the adductor brevis of the thigh ; in 1 case, a fibro-plastic tumour, the size of a child's head, formed within the sheath and in the substance of the sartorius muscle of the left thigh; in 1 case, another cystic tumour, about as large as a goose's egg, springing from the flexor brevis digitorum. Encephaloid cancer formed in the cicatrix, and springing from the muscle just named, showed the nature of the original tumour. In two cases, the tumours were hydatid; one in the deltoid, the other at the outer edge of the latissimus dorsi. In the 7th case, the tumour was an enchondroma in the tibialis anticus muscle. In one other case, enchondroma was situ- ated in the vastus-externus; and in yet another, it was connected with the pectoral muscle. The muscles of the lower limb are most frequently the seats of tumours; in the upper limb, according to Mr. Teevan, the muscles usually, are the pectoralis major, deltoid, and biceps. Those of the neck and trunk are seldom diseased, excepting the rectus abdominis muscle, a frequent seat of tumours. The treatment of muscular tumours differs in no way from that of the same growths situated in other parts of the body. Excision and amputa- tion are the only known resources. Degeneration of Muscles—see General Pathology and Treatment of Degeneration. BURS.E AND SHEATHS OF TENDONS. CHAPTER XXI. inflammation.--GANGLION. Iiuns.K Mucosae. Synovial Bursje.—The bursae are synovial sacs, re- sembling other synovial membranes, and differing only in situation. They are interposed—to facilitate motion—between the surfaces of parts which naturally move on each other. Thus, they are situated, normally, as sub- cutaneous bursae, in the cellular texture between the skin and some firm prominence—e.g., the bursae over the patella; or deep-seated, between a muscle or its tendon and bone, or between two muscles or tendons, and not unfrequently communicating Avith a neighbouring joint. Subcutaneous bursae may be adventitious, resulting from enlargement of the areolae in the cellular texture by continued friction; as beneath corns, bunions, the prominent points of club-foot, and other exposed situations. Such bursae 314 SPECIAL PATHOLOGY AND SURGERY. are, however, imperfect; spaces being thus formed in the cellular texture, rather than bounded by any true synovial membrane. Situations of Normal Bursa.—In the following situation, bursae exist naturally, and are subject, therefore, to injury or disease :—behind the angle of the lower jaw, on the symphysis of the chin, on the angle of the thyroid cartilage, on the acromion, between the lower end of the scapula and the latissimus dorsi, under the deltoid, on the external and internal condyles of the humerus, the olecranon, the styloid processes of the radius and ulna, on the metacarpo-phalangeal articulations, their dorsal and palmar surfaces, and on the dorsal aspect of the phalangeal articulations ; on the anterior superior spine of the ilium, the great trochanter, the tube- rosity of the ischium, and under the gluteus maximus, on the patella, on each condyle of the femur, the tuberosity of the tibia, in the ham, on the two malleoli of the tibia, the os calcis, the dorsal surface of the toes, and the plantar aspect of the heads of the first and fifth metatarsal bones. (1) Inflammation of a bursal sac may occur, with enlargement and distension of the sac with synovial secretion. Suppuration soon follows, and the formation of abscess, which bursts externally or into the sur- rounding cellular membrane. This texture is also liable to become involved as the abscess progresses. The resulting ulcerations are singularly obstinate. (2) Chronic enlargement of a bursa, from long continued pressure and irritation rather than inflammation—is another condition of common occurrence. The bursa becomes distended with contents of variable nature, partly fluid and solid; as an increased sero-synovial secretion of clear straw-coloured fluid, or a brownish fluid, thick and grumous, ap- parently due to altered blood, or adhesive and containing cholesterine. Fibrinous matter is occasionally deposited on the interior of the sac, gradually producing considerable thickening of the wall of the sac. Within the sac, numerous small flattened and elongated bodies may form, resembling melon-seeds or parboiled rice ; and which result, apparently, from disintegrated fibrinous matter subjected to motion and attrition, or from the detachment of pedunculated fibrinous matter from the interior of the sac. The origin and production of these bodies is thus similar to the formation of loose cartilages in joints, and they gradually acquire a fibro-cartilaginous character. Lastly, fibrinous deposit progressing con- centrically, may at length convert the bursa into a solid tumour, having a laminated structure, or leaving a small central cavity containing a gela- tinous fluid. The diagnostic character of these various structural conditions is tolerably obvious. Inflammation, followed by suppuration and abscess, sloughing and ulceration ; will be severally attended with their usual signs and symptoms. Enlarged bursae are chronic indolent tumours ; with distinct fluctua- tion, denoting fluid contents, or having a solid resisting character accord- ing to the deposition of fibrinous matter. Thickening of the sac forms a semi-solid tumour, and the production of melon-seed-like bodies sometimes yields a crackling sensation on handling the sac, while complete solidifica- tion presents a hard elastic tumour. Causes.—Some local injury, as pressure, friction, or a blow, is generally the cause, whether of inflammation or simple enlargement of a bursa. Occasionally, some constitutional tendency seems to have a pre- disposing, or possibly productive influence. PARTICULAR BURS.E. 315 Treatment.—Inflammation may be subdued by rest, cold or warm fomentations, and topical bleeding. Suppuration having occurred, a free opening must be made and poulticing continued until granulation is esta- blished. Chronic enlargement of a bursa yields to various methods of treatment according to the nature of its contents. An accumulation of serous fluid in the sac may be absorbed by a stimulating application, such as iodine paint, which I prefer. By puncturing the sac and pressure, or by the injection of iodine, adhesion may be induced; or the introduction of a seton for a few days may lead to suppuration and contraction. Fibrinous matter having been deposited, thickening of the sac, and an accumulation of melon-seed bodies within its interior, may possibly be cured by a seton, inducing discharge and contraction. But this condition, or that of complete solidification, generally necessitates removal of the bursa surgically. When fairly dissected out, the disease can never return, and commonly no evil consequences follow this operation. In one case only, after I had thus extirpated an old enlarged bursa patellae, phagedaenic gangrene appeared in the wound, and spread to some distance above and below the knee. But this was, evidently, an accidental concurrence, and no valid objection to the method of treatment. Particular Bursae.—Bursa Patella.—The bursa situated over the patellae is liable to the same diseases as those common to all bursae. In- flammation and its consequences, or simple chronic enlargement, not un- frequently occur. " Housemaid's knee," as it is called, is an inflammatory affection of the bursa patellae; arising from frequent pressure and irrita- tion by kneeling on a hard surface. But the same condition may be pro- duced in other females and in males, under similar circumstances. Caries of the patella—consequent on abscess of the bursa—possibly involving the knee-joint eventually; seems to be the only pathological peculiarity worthy of notice in connexion with this disease. The treatment is the same as that of bursal affections in general; the treatment of inflammation and suppuration; or, in a chronic state, stimu- lating applications, puncture and pressure, injection, a seton, or extirpation by careful dissection, having regard to the proximity of the joint to the enlarged bursa. Bunion.—Inflammatory enlargement of the bursa situated on the inner aspect of the metatarsal bone of the great toe, or of an adventitious bursa formed in that situation, is the essential element of a bunion. The sac con- tains an increased quantity of thin serous fluid, or a dense crystalline secretion oc- casionally, as observed by Sir B. Brodie and M. Boyer. Over this enlarged bursa, a corresponding portion of thickened and horny cuticle, a large corn forms; both of Avhich constitute the bunion. (Fig. 51.) The toe is generally displaced obliquely outwards, lying over or under the adjoining toes; thus forming an angle more or less obtuse at the metatarso-phalangeal articu- lation, or root of the great toe, and con- siderably increasing the prominence inwards. Acute pain, redness and heat—the symptoms of inflammation—accompany this swelling; it being partly an inflammatory enlargement of the bursa. 316 SPECIAL PATHOLOGY AND SURGERY. Chronic bunion represents the result of this state, inflammation having subsided into a tolerably painless enlargement of the bursa; but which is liable to become acute, occasionally. The cause of this condition is the pressure of a tight and narrow- pointed boot or shoe, habitually worn; whereby the toe gradually becomes turned outwards from its natural direction, increasing the pres- sure on the root of the toe projecting inwards. The formation of bunion is, therefore, mostly secondary to, and the consequence of, this displace- ment of the toe. Continued and increasing pressure thus bearing on the root of the toe, the bursa there situated enlarges or a new one is pro- duced, and the superimposed cuticle becomes a corn. The course of bunion is apt to be very destructive. The internal lateral ligament yields under the constant strain, suppuration within the bursal sac frequently supervenes, the abscess slowly progressing to the surface and opening by a small circular aperture in the centre of the horny callosity ; or destroying the ligament and involving the joint; the cartilages are eroded, the bones become carious, and partial dislocation inwards is permanently established. Some relief of the intolerable pain and of the other inflammatory symptoms, follows any evacuation of matter ; but an indolent and unhealthy sore remains, indisposed to heal. Treatment.—Removal of the cause in operation is primarily important. A large shoe should be worn, or one with a compartment for the great toe, so as to keep the toe in a line with the metatarsal bone, and thus relieve pressure By a contrivance of Mr. Bigg, the toe can be drawn inwards. A compress of thick soft leather, spread with soap-plaster, and cut in the form of a horse-shoe, or a circular piece with a hole in the middle, may be applied; the opening corresponding to the bunion, which is thus relieved from pressure. Inflammation is to be overcome by the usual topical applications: poulticing or cold lotions according to the state of the bunion. Abscess forming in the bursa, an opening should be made without delay, both to relieve the intense pain and prevent any destruction of the joint. Chronic bunion is best removed by painting it with a strong solution of nitrate of silver. A large, and perhaps painful cyst, may be destroyed, as recommended by Sir B. Brodie and M. Boyer, by an incision into the sac, and cauterizing its inner surface with nitrate of silver or nitric acid. It should be observed whether the sac communicates with the joint. Destruction of the internal lateral ligament, and the articulation, may terminate well, by fixing the joint with a gutta-percha splint; or this con- dition may necessitate excision or amputation of the toe. The latter operation has been resorted to successfully, in some cases. Sheaths of Tendons.—(1) Tenosynovitis—acute and chronic.—Sheaths of tendons in the neighbourhood of joints, are most liable to inflamma- tion. The flexor and extensor tendons of the wrist, for example, are subject to strains in various laborious occupations. To guard against any such injury, it is not uncommon for navigators and others similarly employed, to wear a band around the wrist, as a support to the tendons. Puffy swelling and some pain in the course of tendons, after injury, denote inflammation of their sheaths. A peculiar creaking, jerking, sen- sation and sound, is elicited on moving the part. This latter sign differs from the true crepitus of fracture. The treatment is in no way peculiar. Rest, and warm fomentations; PARTICULAR BURS.E. 317 followed by stimulant applications and pressure in the chronic state of inflammation. Blistering, embrocations, and a bandage are thus effica- cious ; or the emplastrum ammoniacum cum hydrargyro employed as strapping, is both stimulating and supporting to the part affected. (2) Ganglion.—This is a simple or barren cyst or sac, attached to, but communicating with, a sheath of a tendon. It contains a firm, trans- parent Avhitish, gelatinous matter, resembling the vitreous humour of the eye. The cyst varies in size and shape, from a pea to a filbert; and presents a corresponding tumour, smooth, elastic, moveable, and subcuta- neous; situated usually on the back of the wrist, occasionally on the dorsum of the foot. This little tumour is itself painless, even when pressed firmly under the thumb, although thep atient experiences a sense of Aveakness in the joint. Chronic ganglion does not so much increase in size, as the cyst attains considerable thickness and resistance. Arising from a sprain, or as it were spontaneously—unlike a subcutaneous bursa which proceeds from pressure—ganglion is usually of sIoav growth, but, sometimes, makes its appearance quite suddenly. Compound Ganglion is described by Erichsen, as a dilatation of the sheaths of the tendons ; often attaining a very considerable size, and usually becoming irregular in shape, several tendons being implicated in it. Often the sheath is thickened as well as dilated, and highly vascular, being lined with a red, fringed, and velvety membrane ; the contained fluid is clear and yellowish, but usually thinner than in simple ganglion ; or the fluid may be dark and bloody, containing masses of buff-coloured fibrine or a large number of granular bodies, like those met with in enlarged bursae. " These bodies are composed of perfectly developed granulations, in which the remains of blood-vessels are visible, probably thrown off from the inner wall of the vascular sheath." Compound ganglion is chiefly met with in the palm of the hand, and on the dorsum, sole, or inner side of the foot. This form of the disease is extremely chronic, may acquire an almost malignant appearance, and occupy a very extensive surface ; in one case, the dorsum and greater part of the inner side of the foot were involved. Simple ganglion, however, in this situa- tion is larger, flatter, and less moveable than on the back of the wrist. In some instances, Mr. Tatum has seen such a ganglion, on the outer part of the back of the foot, more than two inches in diameter and compressed. Treatment.—Simple ganglion is, usually, amenable to remedial mea- sures. In its ordinary situation, on the back of the Avrist, a ganglion may be dispersed by squeezing it with the thumbs, or by a blow with the back of a book ; the sac bursting and evacuating its contents under the skin. A chronic ganglion, having a thickened sac, may require consider- able pressure before it yields, and the sac remaining may still give the appearance of a ganglion; deceiving both the operator and the patient, unless the sensation of bursting be noticed during the application of pressure. Sometimes, the cyst refills, and it may be necessary to continue pressure by means of a compress and roller, firmly applied. Occasionally also, other measures as for an enlarged bursa, are requisite; puncture and pressure, a seton, or extirpation by dissection. Compound ganglion—distension of the sheaths of tendons—is a far more obstinate disease ; especially, Avhen occurring in its usual situation, the palm of the hand. The sheaths of the flexor tendons are distended, containing a glairy or other fluid. The elastic tumour, thus formed, 318 SPECIAL PATHOLOGY AND SURGERY. beneath the palmar fascia, extends under the transverse ligament into the forearm, in the form of a double swelling, constricted by the ligament. The fingers are contracted. The treatment by free incision of the tumour, dividing the annular ligament, and healing from within, as re- commended by Syme, may be advisable, although apparently an extreme measure. But other proceedings; the passage of a seton from above under the annular ligament into the palm, or the injection of iodine, are more hazardous, as methods of treatment by inducing inflammation. NERVES. CHAPTER XXII. INJURIES.--NEURITIS.--NEURALGIA. Injuries.—Nerves are seldom injured alone, but in connexion with other textures, the injury being shared in common with them. Nerves are, however, liable to similar lesions as other soft textures ; wounds, incised, punctured, and contused, and to contusion without breach of continuity. Perhaps, the latter lesion is the most frequent, as when the ulnar nerve at the elbow is contused by an accidental collision, just catching the nerve in its course between the inner condyle and olecranon. The symptoms attending these forms of injury vary with the amount of injury to the nerve, and its own functional importance. Pain, tingling or other perverted sensation, accompany contusion; complete paralysis of sensation, and of motion, in the parts supplied by the nerve, denote division. This has happened in excision of the elbow-joint; division of the ulnar occasioning immediate loss of sensation on both sides of the little finger and inside of the ring finger, with inability also to move these fingers. Sometimes, loss of temperature, and failure of nutrition super- vene ; owing probably to the loss of nervous influence on the circulation in the part to which the nerve is distributed. Fortunately, restoration after contusion, and reunion, after division, not unfrequently take place; the nerve sooner or later resuming its func- tions. The treatment will, therefore, be guided by these considerations. Rest in all cases, and apposition of the ends, if the nerve be divided. Neuritis.—Inflammation of Nerve.—Symptoms.—Pain, severe and continued, shooting along the nerve or nerves affected ; and rendered intolerable by pressure in their course, or on attempting to move the part. Jerking of the muscles often occurs. Some heat and swelling along the course of the nerve may perhaps be detected, if the inflamed nerve be situated near the surface. Marked inflammatory fever is present in all cases. Chronic neuritis is attended with a subsidence of all these symptoms, leaving the nerve still sensitive, and sometimes painful; and the individual worn out by suffering and sleeplessness. Causes.—Usually arising from injury; the various lesions to which nerves are liable may induce inflammation, extending along the sheath of the injured nerve. But neuritis may also proceed from some blood- poison, of which it is the local, or one of the local, manifestations. NEURALGIA. 319 Sciatica is probably a manifestation of this kind ; a rheumatic inflamma- tion of the sciatic nerve. Treatment.—Local blood-letting and warm fomentations are most suitable in neuritis of traumatic origin. Rheumatic neuritis must be treated, locally and constitutionally, as acute or chronic rheumatism. Neuralgia.—Symptoms, and Diagnosis.—Pain is still the essential symptom as in neuritis. It may be even more severe, or excruciating, but it is paroxysmal; shooting along the course of a nerve, or diffused, but commonly relieved by firm pressure, although generally induced by the slightest superficial touch or movement of the part. Various anoma- lous sensations may be experienced, as creeping, tickling, or burning in the part. Spasm of the muscles is a frequent concomitant. Slight heat, puffiness, and redness may supervene, and increased secretion, as of tears or saliva when the nerves of the eye or jaw are affected. But no fever of an inflammatory character accompanies the attack. Its duration is usually much shorter than neuritis; lasting perhaps only a few minutes, although prolonged indefinitely in some cases. The periodical return of neuralgia, at a certain time in the day, or in certain months of the year, is also characteristically distinctive. From structural disease of the part, neuralgia is distinguished by the absence of any special physical signs—e.g., inflammatory swelling, and of fever; and also by the character and disproportionate severity of the pain. From hysterical pain, it differs in mostly being restricted to one part, and by the absence of general hysterical symptoms. The association of structural disease Avith neuralgia Is sometimes most perplexing. But here—and with regard to hysteric pain—the diagnosis may be determined by the aggravation of the pain by deep pressure, rather than any marked cutaneous sensibility. The mistaking structural disease for neuralgia, would mislead the treatment; but this error is not so seriously misleading as the mistaking neuralgic pain for structural disease. By attention to the foregoing points of distinction, the fine may generally be safely draAvn between neuralgia and disease of the joints, the breast, testicle, and other parts. Certain nerves are more frequently the seat of neuralgic pain. The divisions of the fifth pair are specially liable ; and in particular the supra- orbital branch. But neuralgia may occur in perhaps any part of the body ; in the scalp, ear, nose, back of the neck, the back, chest, abdomen, arms, ball of the thumb, legs, feet. Causes.—Constitutional conditions, mostly of an obscure character, seem to be the essential cause of all this suffering. A generally depressed state of the nervous system, and circulation of the blood, may be said to represent the constitutionally causative condition, usually apparent. Thus, constant exposure to wet and cold, the climatic influence of damp localities, or periods of the year, depressing passions, not unfrequently induce neuralgic attacks in persons previously healthy. Certain blood- poisons are less obvious, but not less potent. The malarious poison of marshy districts, is thus sometimes the source of the most severe and persistent neuralgia. Chlorosis from amenorrhoea is another such cause. The influence of blood-conditions may be even more conspicuous, in albuminuria; a disease in the course of which, I have witnessed neuralgic attacks of more intense agony, than in any other disease. Local irritation is often the immediate and exciting cause. A carious tooth, or piece of dead bone elsewhere, the accumulation of scybalous matter in the 320 SPECIAL PATHOLOGY AND SURGERY. intestinal canal, or other sources" of irritation, centric or eccentric, are causes of this kind. The pressure of a tumour in the course of a nerve, or a neuromatous tumour itself, would sometimes appear to be causes of neuralgia; but any injury to, or disease of the nervous system, is in this sense causative. Dr. Pemberton suffered for many years from excruciating pains in his face, to relieve which, Sir A. Cooper severed the three divisions of the fifth nerve, on different occasions, without avail. Driven from practice, and worn out by protracted suffering, at length death brought that release which art had failed to give. A tumour was then found in the brain; and thence the origin and persistency of the pain endured during life. Similar instances of sympathetic pain are cited in the work on " Principles," p. 674. Course and Terminations.—Neuralgia is as uncertain in its subsequent history, as its pathology and etiology are obscure. The attacks may cease suddenly, leaving the individual in apparently good health, or soon to recover from the temporary exhaustion consequent on pain and sleepless- ness. Or the sufferer at length succumbs, dying from sheer exhaustion. Treatment.—The cause or causes in operation must be diligently sought for, in each case. It will be useless, however tempting, to remove a merely local cause, when the constitutional condition is still in operation. A change of residence from a damp or malarious locality, may thus be necessary. Other depressing circumstances already noticed, are less under control. Medicinal treatment may, however, do something, preventive or curati\re. Quinine, in large doses—two, three, five grains, or more, will sometimes ward off an attack or cut it short. Quinine treatment continued in smaller doses, sometimes proves curative. Preparations of iron, the sulphate in particular, are more effectual in neuralgia of malarious origin. In albuminuria the blood restorative action of iron, is counteracted by the constant retention of urea and other excrementitious matters in the blood. Disordered menstruation must be remedied by the administration of emmenagogues—e.g., galbanum, myrrh, &c, in conjunction Avith tonic treatment. Constipation or irregular action of the bowels, by aperients, chosen according to the occasion. Thus, aloetic purgatives, rhubarb, mercurials, and salines, are all useful, in different cases. Any local cause of irritation must not be overlooked, but its removal will seldom overcome a true neuralgic tendency. The extraction of a carious tooth, for example, seems only to divert the recurrence of pain to another, and possibly sounder tooth. Local applications—sedative or counter-irritant—are comparatively useless. Belladonna, opium, aconitina, and other powerful sedatives have been tried in vain. The hypodermic injection of morphia is, perhaps, more promising. Blistering, or stimulant embrocations, will rarely be tolerated by the patient. Section of the nerve is a last resource. It cannot succeed in cases of neuralgic pain depending on pressure in the course of a nerve, unless the occasion of pressure can be detected, and the operation be performed above that part. It was thus unavailing in the case of Dr. Pemberton. When appropriate, the section must be an excision of a portion of the nerve, the simply divided ends otherwise regaining their continuity. Neuromatous Tumour.—See Morbid Growths. 321 ARTERIES. Fig. 52. Fig. 53. CHAPTER XXIII. INJURIES OF ARTERIES.--ANEURISM. Wounds--and of Special Arteries.-—These Injuries are conveniently associated, respectively, with Wounds in general (Ch. XIV); and with 1 raumatic Aneurisms in various parts of the body. (Ch. xxiv.) Aneurism.—Structural Conditions. —Aneurism may be generally defined to be a collection of arterial blood communicating with an artery, from Avhich it has arisen. (Fig. 52.) This collection of blood may be circumscribed, commonly, by enclosure within a dilated portion of the artery, as a sac, forming true aneurism ; or possibly within a sacculated dilatation of its external cellular coat alone, tho internal and middle coats having be- come ruptured—mixed aneurism; or, the blood may become enclosed Avithin condensed cellular texture of the part, external to but adjoining that of the artery, thus forming a sac enclosing blood, and constitut- ing circumscribed false aneurism ; or, the blood having escaped from the artery into the adjoining cellular texture, may remain diffused therein, constituting diffused false aneurism. Whether this condition shall remain, or form a circumscribed false aneu- rism, Avill depend chiefly on the de- gree of looseness or density of the surrounding cellular texture, on the size of the artery, and the direction of the opening in it; and, moreover, is regulated by the force and rapidity of the current of blood passing through the vessel. The accompany- ing figure represents a diffused aneurism becoming circumscribed. (Fig. 53.) Other forms of Aneurism are recognised by Surgical Authors. Fusiform or Tubular Aneurism, is a dilatation of all the coats of an artery, extending throughout the entire cir- 322 SPECIAL PATHOLOGY AND SURGERY. cumference of the vessel, and not forming a sac. It commonly occurs in the arch of the aorta. Dissecting aneurism, is sacculated, but the sac is formed between the coats of the artery, and generally between the internal and middle coats, which have become separated or dissected up by the force of the blood, the inner coat having given way. The sac thus situated may extend a considerable distance along the vessel. This condition was first described by Shekelton. Signs.—The physical signs of aneurism vary with its condition. True aneurism at first presents a small, soft, circumscribed tumour, pulsa- ting, to the touch, to the eye, and to the ear,—as a rasping or sawing sound or bruit,—in unison with each beat of the heart. The pulsation ceases and the tumour itself subsides, if the current of blood through the aneurismal sac be arrested by compressing the artery above the aneu- rism. And, at this early period, the sac can be emptied by pressure, and the blood thus returned into the artery. Mixed, and circumscribed false aneurism, respectiA-ely, are not characterized by any peculiar signs; either of these forms of aneurism presenting a circumscribed tumour, and in its early stage, beating and thrilling under the finger, yet being also reducible. Seeing then that the signs of these three forms of aneurism are indistinguishable, their distinctive names are practically useless. In the course of time, the aneurismal sac, enlarging and borrowing more and more fibrine from the passing stream of blood, becomes partially con- solidated. The tumour, as felt externally, is, therefore, no longer soft, although still circumscribed; its pulsations are fainter and less expansive, and the swelling cannot be reduced by compressing the vessel above, nor by direct pressure without such force as would break up the clot. The sound or bruit also, produced by the pulse-wave of blood through the aneurism, may now be absent; as when the neck of the sac is too narrow to readily admit the current of blood into the sac, or if the sac be con- solidated Avith coagulum. Hence, the characteristic signs of aneurism are modified or absent. Diffused false aneurism, in virtue of its essentially distinctive condition from that of any circumscribed aneurism, might be designated simply,— Diffused Aneurism. The tumour is generally of much larger size than a circumscribed aneurism; its outline is no longer defined, the pulsations are fainter and more indistinct or quite imperceptible ; and the blood, being infiltrated, cannot be returned into the aneurismal artery. The swelling resembles a large ecchymosis, the superjacent integuments being discoloured like an extensive bruise. The limb or part dependent on the artery for a due supply of arterial blood, becomes cold and oedematous, threatening gangrene. If the diffused form be consequent on circum- scribed aneurism, the individual felt something give Avay suddenly, followed immediately by notable enlargement of the aneurismal swelling; accom- panied with intense pain and faintness. The former symptom is due to pressure from the diffusion of blood among the textures and possibly under unyielding fasciae : the latter symptom arises partly from shock, by the pain thus caused, and partly from the loss of blood in circulation, by its effusion. The functional symptoms of aneurism, are, pain, loss of muscular power, and venous congestion. These do not occur until a rather late period of aneurism, and do not accompany it throughout its career. They, therefore, are neither primary nor constant manifestations, and are inap- plicable in aid of an early and exact diagnosis. [P. p. 173L ANEURISM. 323 Diagnosis.—The physical signs of aneurism, already described, may themselves be absent; as Avhen consolidation in the sac has taken place. Or, if these signs be present, they may arise from other causes, other pul- sating tumours. Such are, vascular or erectile tumours, and certain tumours of a highly vascular character, as encephaloid cancer. The diagnosis will be determined by comparing the signs of these Tumours with those of Aneurism. Then again, a tumour or an abscess seated on an artery, pul- sates, and thus simulates aneurism. But, the pulsation of any superim- posed mass is not expansive and uniform over its Avhole surface ; the tumour does not subside if pressure be made on the artery above, although the pulsation ceases; and it cannot be emptied by direct pressure. It should, however, be remembered that these negative signs are equally true of aneurism which has undergone consolidation. In some doubtful cases, the tumour can be lifted off the artery; thus plainly declaring its independence. There are also frequently present the characteristic signs of the particular kind of tumour or swelling. Diffused aneurism is far less likely to be equivocal, its signs being more peculiar. The history of aneurism will further aid in determining its diagnosis. If the tumour be circumscribed, by conversion from diffused aneurism; there will be the antecedent transition changes from that condition. If diffused, by conversion from circumscribed aneurism, there will be ante- cedent transition changes from that condition; if originally diffused, there will be the antecedent fact of traumatic origin. Causes, and Effects of Aneurism.—Aneurism commonly arises from an internal cause ; namely, a diseased or atheromatous condition of the artery, by fatty degeneration—oil-particles, with crystals of cholesterine (Fig. 54), and subsequently calcareous degeneration; affecting the middle Fig. 54. Fig. 55.* * Fatty degeneration of cerebral arteries ; a, ultimate capillary ; b, larger vessel; c, small artery. (Wedl.) Y 2 324 SPECIAL PATHOLOGY AND SURGERY. having lost its elasticity, and perhaps being partially ruptured, is dis- posed to yield to the pulsating action of the arterial Avave-current, and expand into an aneurismal sac. Hence, the formation of idiopathic Aneu- rism, which is primarily circumscribed, and secondarily only becomes diffused, by rupture; or eventually perhaps again circumscribed, by fibrinous consolidation. The number of aneurisms which are liable to form, simultaneously or successively, in the same individual, is mainly determined by the nature of the internal cause in operation. Fatty and calcareous degeneration not unfrequently affects a large extent of an artery, as the aorta, or many arteries, as both popliteals and other vessels. Thence the production of more than one, and even numerous aneurisms in the same person. Sixty- three, for example, were found in one individual, whose body was ex- amined by Pelletan. Predisposing Causes, vary in their nature and degree of influence. Age is important, but apparently only as connected with those degenera- tive changes which the arteries, in common with many other textures, undergo as life advances. Thus, aneurism is most common about the middle period of life, or between the ages of thirty and forty, and subse- quently. Certain blood-diseases seem to have some predisposing influence. Syphilis, gout and rheumatism, have this reputation. Climate appears to possess an inexplicable predisposition ; aneurism being far more common in cold than in hot countries. The immunity of the East Indies contrasts favourably with the climate of Great Britain and Ireland. Occupation has an unquestionably important influence, and especially in connexion with previous habits of life. Thus, any violent exertion, and by persons who are habitually sedentary, is conducive to aneurism. Hunting, pedes- trianism, and other athletic sports, may therefore have this tendency. Such pursuits seem to favour the production of aneurism, by repeatedly exciting a powerful action of the heart and compression of the arteries, in muscular exertion. Sex is thus associated with predisposing causes; aneurism occurring more frequently in men than women, in about the proportion of 7 to 1. But, the influence of this and other sources of pre- disposition, is very variable, and undetermined with regard to their causa- tive importance. The external causes of aneurism are injuries of various kinds affecting the arteries; as, an external wound, a fracture or dislocation, opening an artery; or, a strain, or bruise, inducing sloughing of the vessel. Hence the formation of traumatic Aneurism ; Avhich is primarily diffused, and secondarily only becomes circumscribed, in favourable cases. It appears then, that Aneurism arising idiopathically or traumatically, may, respectively, be found either circumscribed or diffused; and con- versely, Aneurism, in either of these structural conditions, may, respec- tively, have arisen idiopathically or traumatically. These relations of origin and structural condition, in respect to Aneurism, are clearly represented in the folloAving Table :— Aneurism. TJ. , . { Circumscribed—primarily. (Idiopathic < -r.-nc j jI -| ^ . . I r ( Diffused—secondarily. ° ' *a m x. ( Diffused—primarily. I Traumatic ■ adverse condition. But this can scarcely be discovered prior to operation. A rapidly enlarging aneurism is un- favourable, as evincing an indisposition to the deposi- tion of laminated fibrine. Then again, a very large aneurism is unpropitious, as threatening gangrene of the limb ; an event almost inevitable, if the circulation were suddenly cut off by ligaturing the artery. Inflammation of the sac will be an unfavourable condition, by possibly proceeding to suppuration ; and suppuration itself would be a positively forbidding condition, by rendering the result of ligature abortive. The Hunterian operation, first performed in Decem- ber 1785, consists in applying a ligature, on the cardiac side of the aneurism, to a sound portion of the artery ; and therefore at some distance above the aneurism. For popliteal aneurism, the superficial femoral artery ^ is ligatured, where this vessel is crossed by the sartorius muscle, in the middle third of the thigh. The force of the current of blood having been thus reduced, coagula- tion within the sac is promoted, yet without cutting off the supply of blood entirely. A sufficient quantity is transmitted for the process of coagulation, by collateral branches issuing from the artery above the ligature and communicating with the vessel below, but above the aneurismal sac ; while there is also a sufficient quantity of blood transmitted onwards, and also by collateral branches which become adequately enlarged, for the maintenance of the limb below. (Fig. 59.) Meanwhile, coagulation and the deposition of laminated fibrine is pro- ceeding in the aneurismal sac, and it extends into the artery as high, perhaps, as the ligature; both the sac and this portion of the artery thus become consolidated; the ligature separates, in the usual manner by sloughmg of the ring of artery within the noose, and the divided S a 334 SPECIAL PATHOLOGY AND SURGERY. ends of the vessel are simultaneously sealed with plastic lymph. This takes place in a period ranging from ten days to a month; but varying chiefly according to the size of the artery, and the plastic power of the individual. Of fifty-four cases recorded by Crisp, in which the femoral artery was ligatured, the average period for the separation of the ligature was eighteen days. Finally, the consolidated aneurism and artery undergo partial absorption ; so that the latter withers and degenerates into a fibrous cord. The limb, nourished by the collateral circulation, may nevertheless become somewhat atrophied. (b) Anel's operation, 1710, contrasts with the Hunterian, in its ultimate purpose, more than as an operative procedure. The operation proposed by Anel, was to ligature the aneurismal artery, on the cardiac side, but close to the aneurism. (See Fig. 58, left figure.) The aneurismal blood escaping through the distal portion of artery, the sac would, it was thought, collapse, and thus the tumour disappear. For this purpose, the blood must remain fluid in the aneurism, instead of undergoing coagulation and the deposition of laminated fibrine, with occlusion of the sac, followed by the absorption of both, the tumour dis- appearing in that Avay, Although, then, these two operations are someAvhat similar, they differ widely in their ultimate purpose as to their modes of cure. Moreover, Anel, having performed his operation once only, and for traumatic aneurism of the brachial artery at the head of the elbow, he never himself repeated it, nor advocated its repetition, in similar cases. He apparently regarded his operation as applicable only in that particular case; unlike Hunter, as a conception ruling the treatment of a large class of cases. It is with reference to idiopathic aneurism—as implying a diseased state of the artery—that the operations of Anel and Hunter notably contrast; and when compared Avith the only operation which had previously been designed for the cure of such aneurism. The old operation, or that of Antyllus, consisted in extirpating the aneurism. An incision was made throughout the whole extent of the aneurismal sac, in order to scoop out the coagulum and expose the two orifices of the artery leading into the sac; immediately above and below those points a ligature was passed round the vessel, securing it in both directions. But an unsound portion of artery was thus selected—that immediately above and below the sac, which participated in the degenera- tive change of structure that originally gaAre rise to the aneurism. Hence, secondary haemorrhage, perilous or perhaps fatal, generally occurred Avhen either ligature separated, and as often necessitated amputation; while invariably, the large wound of the aneurismal operation healed tediously and often precariously to life by exhausting suppurative discharge. In Hunter's operation, a sound portion of artery was selected, thus avoiding these evil consequences. This operation, therefore, at once superseded that of Antyllus, and Anel's also—the ligature having been applied equally close to the aneu- rism in that operation. But the principle of Hunter's operation—in relation to the natural cure of aneurism, differed even more essentially from both these operations; in the assumption that it was necessary only to reduce the force of the circulation by applying the ligature at some distance from the aneurism, for the process of natural cure to supervene, instead of entirely arresting the current of blood through the aneurism by ligaturing the adjoining portion of artery. Signs after Ligature, by Hunter's Operation.—Certain alterations in the ANEURISM. 335 signs of aneurism, attend or follow the Hunterian operation of ligature. The aneurism ceases to pulsate and partially subsides. These changes taking place immediately the ligature is drawn tight, are valuable signs of its successful application. The circulation of blood being proportionately arrested in the limb, it becomes numb and cold, and its muscular power is diminished. As the collateral circulation is established, these immediate effects disappear, and the temperature of the limb may rise above that of its fellow. After-treatment.—The treatment after this operation should be directed to avert the temporary tendency to gangrene, pending the establish- ment of an adequate collateral circulation. Hence, the circulation and temperature of the limb must be maintained. A thick Avxapper of carded avooI answers most effectually, aided by a suitable elevation of the limb to relieve congestion. A moderately nourishing diet with stimulants, and the judicious administration of opium, will tend to sustain the process of cure. Consequences.—Certain unfavourable consequences and evil results may ensue from this application of the ligature for aneurism. 1. Pulsation may continue or return in the aneurismal sac. The small stream of blood conveyed by collateral branches into the artery beloAV the ligature, and thence into the sac, depositing the laminated fibrine, is not a pulsatory current. If, however, these feeding vessels are larger than sufficient for this purpose, pulsation continues, or soon returns; if they enlarge immoderately, then also pulsation returns. Any regurgitation of blood into the sac, from below, and therefore in opposition to the current, need scarcely be taken into account. If it occur, it will cause gradual enlargement of the aneurism, Avithout pulsation; simulating the gradual increase of a malignant tumour. Rarer causes are these—Any condition of the blood, which, delaying or hindering coagulation, disposes it to remain fluid in the sac, will favour the continuance of pulsation. A vas aberrans may exist, Avhich communicating directly, or indirectly, with the aneurism, thus continues its pulsation. An instance of this kind occurred to Sir Charles Bell.* He ligatured the femoral artery for popliteal aneurism. The patient died a week afterwards from erysipelas; and it Avas then discovered that the femoral artery was double, and that the vas aberrans had continued to supply blood to the aneurism in the ham, after the operation. Yet in this case, the sac had become completely consoli- dated with coagulum, and in the short period of one Aveek. The prepara- tion is in the museum of University College, London. Other contingencies —by which the pulsation of an aneurism continues after the application of a ligature—relate to the operation. The ligature may not have been applied to the aneurismal artery; or having been applied thereto, the noose may have been tied obliquely, instead of transversely, then shifting its place and loosening its hold, the pulsation continues, or returns, soon after the operation. Of all these causes of pulsation after the Hunterian Operation for aneurism, that arising from an undue collateral circulation, as explained, is by far the most common. But it occurs Avith different degrees of frequency in different arteries. In carotid aneurisms it is most frequent. Of 31 cases, in Avhich the carotid artery was ligatured for aneurism, pul- sation continued or returned in 9 ; whereas of 92 cases of inguinal aneurism, in Avhich the external iliac artery was ligatured, pulsation • London Medical and Physical Journ., vol. Ivi. p. 134. 336 SPECIAL PATHOLOGY AND SURGERY. returned in 6 cases only. In axillary and popliteal aneurisms, respectively, recurrence of pulsation is an exceptional event. It should be remembered that a slight thrill may very frequently be felt in an aneurism, on the second or third day, after the application of a ligature by the Hunterian method. This, however, is a favourable occurrence, as it bespeaks a feeding stream of blood for coagulation in the sac ; and it supervenes with about equal frequency in all aneurisms, irrespective of any particular portions of the arterial system, and the distribution of vessels accordingly. The thrill, thus arising, soon subsides—with consoli- dation of the sac. Returning pulsation, on the other hand, if it occurs, usually begins at a much later period, not until a month or six weeks have elapsed, and continues for some time. Returning pulsation is seldom persistent, and rarely terminates fatally. Of 26 cases in which pulsation returned, 3 only were fatal, and then not OAving to this event, but by sloughing of the sac. 2. Secondary Aneurism, or aneurism reappearing by redilatation of an aneurismal sac, which had previously undergone consolidation and absorption, is an extremely rare event. This must not be confounded Avith returning pulsation. Mr. Erichsen believes there are only two un- equivocal instances on record, both of which were in the ham ; the original tumour having disappeared entirely, this secondary disease made its ap- pearance, after the lapse of six months, in one case ; and after four years, in the other instance. Secondary Aneurism, in the sense of another distinct aneurism arising close to the former one, double aneurism, in fact, is quite another matter. Treatment of Pulsation; continuous or returning.—This, of course, must have reference to the cause or causes of the pulsation. Arising, in most instances, from an undue collateral circulation communicating, directly or indirectly, with the sac; the pulsation will cease as the deposi- tion of laminated fibrine proceeds therein. The process of natural cure rights itself. Failing this result; the balance between the deposition of fibrine and the supply of blood, may be slowly gained, or regained by sufficiently elevating the limb; while the pulsation can be directly re- strained by moderate pressure on the aneurism, with a compress and roller, evenly applied. These resources not proving effectual, the coagu- lating power of the blood deserves consideration; but our knowledge respect- ing its operation within the body is at present very limited. Here then pathology fails to guide the treatment. The presence of a vas aberrans is discovered at the time of operation, by ascertaining whether the ligature entirely controls the pulsation of the aneurism. If not, the tributary vessel should be sought. It will not be far off, and it must be secured by another ligature. In like manner, the aneurismal artery is identified, by trying the pulsations of the sac, when the supposed aneurismal vessel is commanded above; but this should be done before the ligature is applied. Lastly, application of the ligature transversely round the artery, Avill avoid any chance of pulsation continuing or returning, as occasioned by shifting of the noose. Extreme cases, which baffle all these resources and precautions, necessitate further operative proceedings. Reapplication of the ligature may have to be resorted to; either lower doAvn the artery—nearer the sac, as an approach to Anel's operation—or, by opening the sac, turning out the clots, and tying the artery immediately above and below—the old operation of Antyllus. I know of no data for determining the Surgeon's ANEURISM. 337 choice, but the latter operation, whereby Nature's work of coagulation and consolidation is undone, should be resorted to reluctantly. Amputa- tion is the very last resource. 3. Gangrene of the limb proceeds from causes of an opposite character to those which induce pulsation in the aneurism, after the Hunterian operation. The latter are conditions which favour an undue collateral circulation through the sac ; the conditions to which I now allude retard any collateral circulation. Firstly ; an aneurism itself retards the current of blood through the artery, and operates also by compressing the neighbouring vessels ; thus preventing the transmission of arterial blood, and the return of venous blood. Gangrene threatens. The application of a ligature to the aneurismal artery is an additional obstruction, rendering the condition more perilous; and if the collateral circulation be interrupted by the large size of the aneurism compressing the neighbouring vessels, then gangrene ensues. Secondly; surgical mis- management of the limb, after operation, by inattention to position and temperature, or the presence of any morbid condition which lowers the vitality of the limb, will severally tend to induce gangrene. It supervenes in a period, varying from the third to the tenth day; but in rare cases, not until the third week. (Porter.) Treatment.—So far as gangrene is due to the ligature, it cannot be prevented ; but if due principally to interruption of the collateral circula- tion by pressure of the sac, this source of obstruction can be removed by the old operation of cutting down upon the sac, laying it freely open, and turning out the clot. At least two such successful cases, both of popliteal aneurism, are on record; one by LaAvrence,* another by Benza. Other preventive measures, topical, dietetic, and medicinal, have already been noticed in reference to the appropriate treatment after ligature. With gangrene, as with recurring pulsation, amputation of the limb is our last resource; and the operation must be performed above the situation of the ligature. 4. Suppuration and sloughing of the sac, is attended with the usual symptoms of inflammation—heat, pain, and throbbing. At length the integuments give way, and portions of clot escape, having various degrees of consistence and shades of blood-red colour. Then haemorrhage of fluid arterial blood occurs, either with a fatal gush, or recurring in small but increasing quantities. Which form of haemorrhage shall take place is apparently determined by the degree to which consolidation of the aneurism has advanced ; and, therefore, in a measure, by the time of its occurrence after ligature. The amount of haemorrhage is regulated in like manner, it being most free and uninterrupted in the event of pulsa- tion continuing or returning. The causes of suppuration and sloughing of the sac, and of haemor- rhage thence arising, in the course of aneurism, are any conditions unfavourable to the vitality of the sac. Hence, the large and increasing size of an aneurism, and the imperfect coagulating power of the blood therein, have this tendency. So also any external injury to, or irritation of, the sac. Considering these and other similar accidental circumstances, the period after ligature Avhen suppuration may supervene, is, obviously, very uncertain. It may happen at any time in the subsequent course of the aneurism. The average time is, perhaps, betAveen the third and eighth * Medical and Physical Journ., vol. Iv. z 338 SPECIAL PATHOLOGY AND SURGERY. weeks, but in a case of carotid aneurism recorded by Sir A. Cooper, suppuration occurred at the eighth month after operation. Comparatively few cases terminate fatally ; probably not more than one in four, and then, generally, by haemorrhage. Treatment.—This will be guided by the stage and result of suppura- tion. In the first instance, the sac should be treated as an ordinary abscess; only that Avhen an incision is made, it should be free enough to turn out the whole of the clot. Any remaining portion is likely to putrify and become a foetid, purulent discharge ; but when removed entirely, the sac is in a condition to heal from the bottom by granulation. Hamor- rhage, of course, is imminent. A tourniquet, therefore, loosely applied to the limb above, will be a judicious precaution which can be brought into use at any moment. In the event of haemorrhage ; loss of blood may be temporarily stayed by a compress of sponge well placed at the bottom of the sac, over its mouth; and of sufficient size to be secured in position by a roller, evenly applied. Then comes the question of hoAv to permanently arrest the haemorrhage ? The diseased state of the artery immediately above and below the sac, in idiopathic aneurism, forbids the application of a double ligature in situ, as by the old operation. Ligature of the artery higher up than Avas performed prior to suppuration, would probably be the turning point for the commencement of gangrene. In this dilemma, the Surgeon may advantageously Avait and see what Nature can accomplish, as the healing process of granulation closes over the arterial aperture in the sac; guarded always by the compress, and during its reapplication occasionally, by tightening the tourniquet. This faithful folloAving up of Nature's operation having failed, our only resource is amputation. 5. Secondary hamorrhage from the operation-wound, after ligature by the Hunterian method, is an event unconnected with the course of Aneurism. It is a failure of the operation; and, as it arises from sloughing of the included portion of artery before the preparatory closure of either or both ends of the vessel has taken place, the haemorrhage occurs whenever the ligature separates. The average time was the 18th day, in 54 cases, recorded by Dr. Crisp, of ligature applied to the femoral artery. It is more likely to occur, the nearer the artery is to the heart, the central force of the circulation. The treatment in this case is not presumed to be restricted by any diseased state of the artery, at the seat of ligature. Consequently, the re- application of two ligatures, one to each end of the artery at the point of division, will most probably prove effectual; the former operation-wound having been just sufficiently reopened for this purpose. Temporarily, the haemorrhage may be arrested or checked, by plugging with sponge or lint. Statistical Results.—Ligature for Aneurism shows a considerable mortality. In 256 cases of this operation on the larger arteries, the deaths were about 22 per cent. This was shown by Dr. Crisp's tables. The result of investigations by Porta is even more startling. In 600 cases of ligature for diseases and injuries indiscriminately, the mortality rose to 27 per cent. Then again, as compared with compression, the balance is decidedly in favour of the latter mode of treatment. Thus, according to Norris; of 188 cases of ligature for femoral and popliteal aneurisms, 142 were cured, 46 died, 6 limbs were amputated ; in 10 suppuration of the sac supervened, and in 2 gangrene of the foot; giving ANEURISM. 339 a total, of deaths, about 1 to 4, and failures 1 to 3. Whereas, of 32 com- pression cases, also of femoral and popliteal aneurisms, collected by Bel- lingham ; 26 were cured, in 1 ligature was resorted to after compression had failed, in 2 amputation became necessary, in 1 death occurred from erysipelas, in 1 from chest-disease, and in 1 instance, the pressure was discontinued. The failures of compression were, therefore, only as 1 to 5-3; and the deaths only as 1 to 16. Even where compression itself fails, it most advantageously prepares the way for success by ligature. Thus, according to Mr. Hutchinson's Report, in 22 cases of "ligature of the femoral artery, previously treated by compression, 2 only died of gangrene ; Avhereas, in only 10 such cases, without preparatory compres- sion, 3 deaths occurred from this cause. iii. Manipulative, and Operative resources, obediently, or correspond- ing, to the second mode of natural cure—i.e., retardation of the passage of blood, through the aneurism, by obstruction of the distal portion of artery; a piece of clot being dislodged from the sac and washed into the mouth of the distal portion, or becoming impacted Avithin it, some dis- tance off. (1) Manipulation.—This plan of treatment Avas introduced by Sir W. Fergusson. It consists in so thumbing the aneurism as to dislodge a piece of clot into the distal portion of artery. The manipulative procedure designed for this purpose, is thus described.* " The patient was seated in a chair, and I placed the flat end of my thumb on the aneurismal tumour so as to cover the prominence. I then pressed, until all the fluid blood had passed from the sac, and I could feel that the upper side of the aneurism was pressed against the lower. I now gave a rubbing motion to the thumb, and felt a friction of surfaces within the flattened mass. The movements Avere little more than momentary, but they were such as I had preconceived." Two cases of subclavian aneurism were subjected to this treatment; neither was unequivocally successful, and both were attended with very alarming symptoms at the time of manipulation. In the first case, the aneurism never ceased to pulsate, and after eight months, terminated fatally by rupture of the lower and back part of the sac. The axillary artery was found to be firmly plugged with fibrine. In the second case also, the aneurism continued, but the pulse ceased at the wrist. At the end of two years, and after hard work as a sailor, the aneurism itself had disappeared. In both cases, giddiness and faintness Avere immediately produced by the manipulation; and in the second case, these symptoms were succeeded by hemiplegic paralysis of the left side, from Avhich, how- ever, the patient recovered in two months. So far the results of treatment by manipulation were not Arery en- couraging. More disastrous cases occurred in the hands of Esmarchy and Teale of Leeds.J Both were carotid aneurisms. On the other hand, an aneurism of the right subclavian artery, thus treated by Mr. R. Little,§ proved quite successful, although not without the disadvantage of tem- porary paralysis of the arm. Tavo successful cases in aneurism of the lower extremity; one of the femoral artery, treated by Dr. G. E. Black- man, of Cincinnati,|| and the other of the popliteal artery, by Mr. Teale,^[ * Med.-Chir. Trans., vol. xl. p. 1. t Archiv fur Path. Anat. und Physiologie, 1857, vol, xi. p. 410. X Med. Times and Gazette, 1859, vol. i. p. 265. § Ibid., 1857, vol. i. || Western Lancet, June, 1S59 ; also Journ. of Medical Science, New York, 1857, P. 291. ound Fractures may occur ; and Avith the usual signs of thes^ Injuries. Direct violence, is, probably their only cause. The treatment will consist, in the adjustment of the fragments, and their retention in position upon a gutta-percha or pasteboard splint, con- trived according to the fracture. Compound fracture may require excision or amputation. But the removal of only the injured portion of the hand, should ever guide and regulate any operative interference; the hand being a most Araluable member in each of its several parts, and readily recovering from most injuries. Fractures of the Pelvis. — 1. Fracture of the Innominate Bones.— Structural Conditions.—Commonly, the rami of the pubis and ischium are the seat of fracture ; extending also, perhaps, from above the acetabulum backwards across the ilium towards the sacro-iliac articulation ; or it may involve the acetabulum, Assuring its floor, or fracturing its margin. Some- times, the acetabulum is comminuted, or simply divided into its three original segments, and the head of the femur driven into the pelvic cavity; or a portion of the margin being detached, dislocation backwards takes place. In one case, I found the pubic portion of the acetabulum nearly detached, and another fracture at the junction of the descending ramus of the pubis Avith the ramus of the ischium; thus nearly isolating the pubic bone. The preparation is in the Museum of the Hospital. Occasionally, some other and, perhaps, any portion, of these bones may be broken ; as, for example, a rim-like piece of the crest of the ilium. Both innominate bones are not unfrequently fractured, and somewhat symmetrically; as, corresponding portions of the rami of the pubis and ischium. Separation of the symphysis pubis, or of either sacro-iliac articulation, rarely occurs. I have, hoAvever, met Avith this injury to each of these three articulations in the same person; but only once. Little, or no displacement is liable to occur, otherAvise than by mus- cular action; the bones being Avell held together, and cushioned by soft parts. (Fig. 123.) But the pelvic viscera are frequently injured ; rupture of the bladder or urethra, giving rise to extravasation of urine; laceration of the rectum sometimes occurring; or of the larger blood-vessels with intra-pelvic haemorrhage. These visceral or internal injuries, are of far more serious import than the fracture in itself. Fractures of the pelvis 464 SPECIAL PATHOLOGY AND SURGERY. thus have an analogous resemblance to those of the ribs and sternum, and of the cranium or vertebral column, in regard to their visceral relations. The Signs of fracture of the innominate bones are not peculiar. No irregularity of the bone at the seat of fracture may be discovered; but mobility and crepitus, on moving each half of the pelvis backwards and forwards, will be readily perceptible; pain also and inability to support the trunk are experienced by the patient on attempting to move or stand up. Inability to empty the bladder, or bloody urine, denotes some injury to this organ; and occurring with the accident, confirms the diagnosis. Caution, therefore, should always be observed in handling the pelvis, lest any visceral injury be aggravated. Fracture of, or involving, the acetabulum, is indicated by the crepitus elicited on rotating the femur, with the other hand placed over the trochanter. Detachment of a por- tion of the margin, with dislocation, is characterized by the recurrence of dislocation after its reduction, the head of the femur easily slipping out of the acetabular cavity. Separation of the symphysis, or of the sacro-iliac articulations, allows of free mobility, and an interval may even be felt in the situation of such separation. In the case to which I have alluded, I could plainly pass my finger between the symphysis, and so far as to recognise the flat surface of the body of either pubis covered Avith its intermediate plate of fibro-cartilage. The transverse or connecting fibres had given way, as well as the ligaments on each aspect of the symphysis, including the strong sw&-pubic ligament. Causes.—Direct violence is almost the only cause of fracture of the pelvis. A heavy fall, or a crushing compression of the innominate bones, as by a cart-wheel passing over the pelvis, or the force of a squeeze between the buffers of two railway carriages; such, and similar acci- dents, are the ordinary occasions of these injuries; or they result from the equally formidable contusion of gunshot wounds. Indirect violence sometimes produces fracture of the pelvis; as of the acetabulum, Avhen a person falls from a height and alights on his feet. Force applied from FRACTURE OF THE SACRUM. 465 the back may have the same effect; an instance of which is cited by Hamilton—a man aet. twenty-seven, on whose back a number of bricks had fallen Avhile his right knee rested on the bank of a trench. Death ensued in a few days; and a fracture was found extending through the bottom of the right acetabulum, and about one inch and a half of the nm at its upper and posterior margin was completely detached, otherwise than as being retained by a portion of the capsular ligament. Disloca- tion upAvards and backwards could be readily reproduced to and fro. lne femur was not broken. Falls on the hip, striking the great tro- chanter, are perhaps the most common occasion of fractured acetabulum ; the force then being transmitted more directly. . bourse and Terminations.—Union of the fracture takes place generally without difficulty, resulting only in some degree of lameness. This result occurs more frequently in fracture of the acetabulum, with dislo- cation owing to the nature of the injury not having been detected, or the impossibility of maintaining reduction. Permanent lameness ensues. Jiut any visceral injuries are of more serious or fatal consequence. The chief difference in such cases depends on the situation of the injury ; whether, or not, laceration of the bladder opens into the peritoneal cavity, with extravasation of urine internally or externally. In the one case, death is almost inevitable; in the other, urinary infiltration behind or in front of the deep perineal fascia, will be followed by suppuration and sloughing, perilous to life. Treatment.—\ny visceral injury demands immediate attention. A catheter should be introduced to discover the state of the bladder If bloody urine, or other symptoms of injury to this organ or the urethra be present, the catheter must be kept in the bladder, to prevent extrava- sation of urine. In the event of extravasation occurring externally, early and free incisions into the scrotum may avert the full extent of the local mischief, and the consequent typhoid disorder. But the treatment of such Extravasation of Urine is described in a subsequent chapter The fracture itself requires comparatively little surgical manipulation The pelvis should be bound round with a broad roller, or rib-bandage, and the patient laid recumbent at rest on a flat bed or mattress, sufficiently firm to counteract any tendency to displacement. Fracture of the acetabulum must be further secured by means of a long splint, or a hip-splint of gutta-percha, moulded to the side of the pelvis and thi) Periostitis.—Inflammation of the periosteum is usually connected with that of the bone itself-ostitis. The periosteal membrane becomes 486 SPECIAL PATHOLOGY AND SURGERY. more vascular, thickened, softened, and loosened from its connexion with the subjacent bone. These alterations may be seen, sometimes, in the bone of a stump, after amputation. Subsequently, an osseous deposit may take place betAveen the periosteum and bone, with some enlargement and induration of that portion of bone, constituting a node. A syphilitic node, which may be regarded as the type, arises from an effusion of lymph between the periosteum and bone; and proceeding from the former, at length involves the bone. A strumous node, on the other hand, consists of scrofulous matter between the periosteum and bone, in consequence of a carious state of that portion of bone. Suppuration will be noticed as a consequence of Periostitis. (3) Endostitis.—Inflammation of the endosteum, or membrane lining the medullary canal, and cancelli, is, probably, of less frequent occurrence. This membrane, however, undergoes analogous changes to those of the periosteum, when inflamed—increased vascularity, and thickening. A deposit of lymph or pus ensues, in consequence of endostitis. Signs.—Ostitis, affecting the deeper portion of the substance of a bone, is unattended with any appreciable signs, in the first instance. A deep-seated wearing pain, generally precedes any alteration of external appearance. This pain is more severe at night, and aggravated by changes of weather; thus resembling rheumatic pain, for which it may be mistaken. Enlargement of the bone at length becomes perceptible ; with, perhaps, some redness, oedematous swelling, and tenderness of the integument. This swollen state of the integument renders any enlarge- ment of the bone more apparent than real. Softening of the bone, in some portion of its substance, may eventually be detected on pressure; but the diagnosis will be sufficiently obvious, Avithout subjecting the patient to the pain of such examination. Scrofidous ostitis is attended with more considerable enlargement of the bone, and of an indolent character. The surrounding integuments are oedematous, white, and painless ; becoming somewhat red and tender, as suppuration supervenes. The concomitant symptoms of scrofula will also determine the diagnosis. Syphilitic ostitis must be diagnosed entirely by the concurrence of present and past symptoms of Syphilis. Periostitis.—The symptoms are similar to those of ostitis, but more simultaneous, and superficial. A painful, puffy swelling, is presented ; the pain subject to exacerbations, and the swelling acquiring a bony hardness. These diagnostic characters are well illustrated by an ordinary syphilitic node in a subcutaneous bone, as the shin. Endostitis is not characterized by any peculiar symptoms, apart from those of Ostitis. Causes.—Inflammation of bone usually results from external vio- lence or from exposure to cold ; but it arises under the influence of some predisposing constitutional condition of disease. These predisposing causes comprise secondary or constitutional syphilis, or the excessive influence of mercury—of rare occurrence now-a-days; the scrofulous taint; rheumatism; and probably other conditions affecting nutrition. Either class of causes—the traumatic or the constitutional—may be alone sufficient to induce osseous inflammation. The bones most liable to in- flammation are, hoAvever, those most exposed to the action of external agents. Hence, the tibia, cranium, and especially the frontal bone, the SUPPURATION OF BONE. 487 clavicle, sternum, ribs, and bones of the foot and hand, are most com- monly affected. Consequences.—The consequences of inflammation of bone have been. incidentally noticed in describing its structural conditions; and particu- larly in connexion with scrofulous ostitis. They may now be more defi- nitely stated as follow:—(1) Absorption and rarefaction of the bone having taken place ; the osseous texture may be found in this state, before the supervention of much deposit. (2) Induration or sclerosis, having taken place; an increasing deposition of plastic lymph and its Ossification, results in considerable thickening of the substance of the bone, and irregular osseous deposit on its free surfaces. Thus, a long bone becomes thickened in the diameter or substance of its shaft; and deposition proceeding within the medullary canal, its bore is narrowed ; while periosteal deposit, at the same time, enlarges the circumference of the bone. Elongation of a long bone is, sometimes, consequent on its inflammation. The tibia has thus become longer than its fellow by nearly two inches. The osseous substance, resulting from inflammatory indura- tion, is more solid, heavier, and harder than that of healthy bone, increas- ing even to the consistence of ivory; and the nutritious foramina are said to be increased in size. This state of hypertrophy corresponds to the in- flammatory solidification of parenchymatous organs. But, as regards bone, it is a termination by restoration to health, or something beyond the natural condition of healthy bone. (3) Suppuration of Bone—another consequence of inflammation, of an opposite character to induration—merits a separate notice; also Caries or ulceration of bone; and Necrosis, Avhich is analo- gous to sloughing or mortification of the soft textures. Treatment.—In traumatic and acute inflammation of bone—whether in the form of Ostitis or Periostitis—the ordinary remedial measures for Inflammation will, usually, suffice. Warm fomentations, leeches, and rest, with the administration of calomel and opium, are appropriate. In con- stitutional and chronic inflammation, this treatment must be supplemented, or partly superseded, by the general treatment for secondary syphilitic affections, scrofula, or rheumatism. Iodide of potassium is thus often singularly efficacious, in syphilitic or rheumatic ostitis or periostitis. Tension and insupportable pain are more readily and permanently relieved by free incisions, than by any medicinal treatment. In periosteal tension, these incisions should be made doAvn to the bone; in tension resulting from ostitis, an incision may be prolonged, by means of a Hey's saw, through the bone, doAvn to the medullary canal, as Mr. Erichsen recommends. Trephining the bone has been resorted to for the relief of osseous tension. Chronic thickening, unattended with much pain, may be removed or lessened by the application of blisters, iodine and mer- curial ointments. Suppuration of Bone.—Suppuration, in connexion with bone, is liable to occur in either of the three situations described Avith reference to in- flammation ; and it may be either diffused or circumscribed; these con- ditions being also, less definitely, acute or chronic suppuration, respec- tively. Thus Ave recognise;—(1) Osteo-myelitis, diffuse suppuration of bone, within the medullary canal and cancelli; (2) Diffuse Periostitis, and Periosteal Abscess; and (3) circumscribed abscess of Bone, within either the cancellated or compact structure. (1) Osteo-myelitis.—This condition certainly occurs, and not unfre- quently ; but—as Mr. Holmes observes—it is less frequently recognised 488 SPECIAL PATHOLOGY AND SURGERY. at the bedside than in post-mortem examinations. The results are diffuse suppuration, the cancelli being found loaded with pus, while the medullary membrane is usually injected and often sprinkled with ecchy- moses; the periosteum is often partly separated from the bone, but the osseous texture has not generally undergone any appreciable change. At this stage, in the larger bones, the disease usually terminates fatally. Otherwise, the pus may penetrate into adjoining parts, probably into the nearest joint; or central necrosis may ensue. The Signs—during life—are neither absolute nor obvious. Separa- tion of the periosteum, with diffused pain in the bone, and diffuse inflam- mation of the integuments, are equally the symptoms of osteo-myelitis and of diffuse periostitis. An absence of effusion between the periosteum and bone is distinctive of osteo-myelitis; but this condition can scarcely be determined by external examination of the bone, and is often rendered more obscure by the superimposed oedematous swelling. The cause is usually some injury implicating the medullary membrane and cancellated structure of the bone affected. Thus, osteo-myelitis, not unfrequently follows amputations, and other operations exposing the medullary canal. It runs a rapid course, is commonly succeeded by pyaemic infection, and thence terminates fatally. Treatment.—Preventive measures afford the only reasonable chance of anticipating this issue; the cure of pyaemia being beyond the reach of any known remedial agents. The ambiguous symptoms of diffused pain in a bone, with perhaps, some oedematous swelling, will, therefore, warrant the Surgeon in ascertaining the state of the periosteum, to deter- mine the diagnosis. Under these circumstances, an early, free incision should be made down to the bone. If the periosteum is discovered to be separating, without any notable effusion between it and the bone, it will be justifiable to trephine the bone, with the view of giving exit to any matter which may have formed in the deeper cancellated structure. Excision of the affected portion of bone, or amputation of the limb, must be had recourse to, as more extreme measures. (2) Diffuse Periostitis.—This diseased condition is of rather frequent occurrence; but it has hitherto been less noticed in surgical works than its importance demands. Diffuse Periostitis—according to Mr. Holmes' observations—appears to consist in the partial separation of the periosteum from the bone; by effusion of lymph or other products, on the surface of the latter. Copious suppuration soon spreads along the bone, detaching the periosteum, often from one end of the bone to the other. At an early period, neither the periosteum nor the surface of the bone is visibly inflamed. The latter, indeed, may look white and bloodless, or sometimes, slightly worm-eaten ; it yields, on pressure, large drops of blood from the periosteal vessels passing into it, and its superficial layers are more readily separable from the deeper osseous texture, than in health. Ne- crosis is soon established, the whole diaphysis of the bone usually, perish- ing; leaving the articular ends unaffected, and therefore not involving the neighbouring joint. Sometimes, it does not escape. The long bones are more often affected than the flat or irregular bones; and, in the great majority of cases, the femur. Signs.—Arising insidiously, an oedematous, painful swelling is presented — diffuse cellular inflammation — resembling acute rheu- SUPPURATION OF BONE. 489 matism. But, suppuration soon following, the diagnosis is at once determined. The causes, would seem to be some injury to the bone, occurring, how- ever, in a scrofulous or Aveakly person. The disease is said to be met with more commonly about the age of puberty, and in boys more than in girls. It rapidly runs its course; pyaemia frequently supervenes and proves fatal; or the matter burrowing among the muscles, forms numerous fistulous openings, exposing necrosed bone. The dead portion is detached much sooner, apparently, than in ordinary necrosis; and reparation also seems to be equally active. Treatment.—Early and free incisions are here, also, primarily impor- tant. During the process of cicatrization, injections of very dilute hydrochloric acid may be used, as highly recommended by Chassaignac, to cleanse the suppurating cavity and hasten exfoliation of the dead bone. A generally stimulating plan of treatment will be required to support life through this trying ordeal. Chronic periosteal abscess remaining, requires no special treatment. (3) Circumscribed Abscess of Bone.—Always a chronic condition ; this state of suppuration differs also from diffused suppuration, in its limited extent, and in being distinctly circumscribed. The abscess, thus defined, is seated within the substance of a bone, usually its cancellated structure; the cavity is lined by a distinct pyogenic membrane, and the surrounding bone is more vascular than natural, and much indurated. The size of this cavity is never large, probably not exceeding that of a small, chestnut, and containing two or three drachms of pus, greenish-yellow or dark coloured. Always situated in one of the long bones, the abscess is commonly located in its upper or lower articular extremity, and very rarely within the medullary canal of the shaft. The tibia is most frequently affected, and its upper end near the knee-joint; its lower end near the inner malleolus, next in order of frequency ; and among other bones, the lower end of the humerus near the elbow, and the femur, have severally been found the seat of circumscribed abscess. Sir B. Brodie first discovered and described this abscess, and pointed out its appropriate treatment ; since the time of his observations, it has occasionally been met with by other surgeons; and recently, Mr. T. Carr Jackson contributed an instructive Paper Avith three cases bearing on the subject. Symptoms.—Pain is at once the earliest, and most significant symptom. It is of a heavy, aching, and eventually, throbbing character; more severe occasionally, or perhaps periodically—generally during the night, and per- sistent for a considerable period—being probably of some years' duration. This pain is referred to a particular part of the bone at one extremity— in for example, the head of the tibia; and a point of greatest intensity can be discovered by careful palpation Avith the finger, where the slightest pressure produces excruciating agony. A small and slight puffy swelling, or induration, surrounds this spot; and the skin may be adherent to the periosteum, Avithout presenting any discoloration. Beyond this external appearance, little or no enlargement of the bone accompanies the remarkable pain of which the patient complains ; and there is an absence of any symptoms of joint-disease. Diagnosis.—The nature of this disease may, however, be mistaken for chronic rheumatism, or periostitis ; or still more probably, for a neuralgic or hysterical affection. The persistence of the pain is the most distinctive character of circumscribed abscess of bone. 490 SPECIAL PATHOLOGY AND SURGERY. Causes.—This abscess can, sometimes, apparently be referred to injury, or exposure to cold. The influence of tubercular disease, is very uncertain. Early adult life seems to be the period most liable; but the ages in recorded cases have varied from 13 to 50. Males and females have been affected indiscriminately. Course and Terminations.—The abscess slowly enlarging, by the ex- cavation and condensation of the surrounding bone, never attains a large size. Ultimately, it opens into the neighbouring joint, which thus be- comes disorganized; and a disposition to this result is evinced by syno- A'ial distension and swelling from time to time, after exercise. Or the abscess may open externally, and discharge its contents with complete relief to the previous suffering. Cicatrization follows, the cavity filling up as in the termination of other abscesses; and the fibrous material which occupies the space, probably undergoing ossification, obliterates any remnant of the abscess. Treatment.—No topical applications or medicinal treatment have the slightest curative efficacy. But the operative proceeding proposed by Sir B. Brodie is at once simple and safe, affords immediate relief and a permanent cure. It consists in trephining the bone over the seat of abscess, and in thus giving vent to the pus. Chloroform having been administered, a crucial incision is made immediately over the painful spot externally, and extending down to the bone. A small trephine, having no projecting rim to oppose its entry, is then applied, and Avorked through the indurated bone; penetrating to some depth, and entering the cavity of the abscess. The circle of bone is detached and removed by an elevator or gouge, and the pus evacuated. Or, a drop may appear, and the bone must be penetrated further by the gouge until the cavity is entered. Sometimes no pus is discovered on raising the circle of bone ; the exposed surface should then be pierced in various directions to find a drop, and the oozing aperture freely enlarged with the gouge. Otherwise, an abscess may exist, but remain undiscovered. This misad- venture happened to an experienced Hospital Surgeon; the limb Avas amputated, and an abscess found at a small distance from the seat of perforation; showing that the removal of a small portion more of the bone would have preserved the limb. The preparation is in the Museum of St. George's Hospital. Only a small quantity of matter will issue in any case, the abscess itself being small. But the cavity having been fairly opened, the relief following the cessation of tension is instanta- neous. A poultice or water-dressing will suffice during the course of reparation; which proceeding uninterruptedly, a permanent cure is established. An error of diagnosis even may be unimportant as regards the favourable result of this simple operation. For if the disease prove to be chronic ostitis—as happened in the case of one of Sir B. Brodie ;s patients—the removal of a piece of bone will relieve the pain, and may induce a healthier action. Caries or Ulceration of Bone.—The term Caries has been applied to different morbid conditions of Bone. By some Surgeons it has been used to denote scrofulous ulceration, exclusively; and by others, to represent a morbid condition peculiar to bone, as distinguished from that of ulceration affecting the osseous texture. But the pathological iden- tity of Caries and Ulceration is now generally acknowledged; and as such I use the term to signify Ulceration, modified only by the textural peculiarities, of Bone. CARIES OR ULCERATION OF BONE. 491 Fig. 148. Structural Conditions.—Caries is essentially a disintegration of the osseous texture; and like ulceration of the soft textures, it may be pre- sented in two forms—as enlarging a pus-discharging cavity or abscess in the substance of Bone, and as affecting the surface of a Bone. Carious bone is softened, and easily breaks down under pressure with a gritty resistance; it is porous, and infiltrated with a reddish-brown oily fluid, and granular inorganic matter—the debris of the disintegrated texture. Small detached masses of dead bone may be found associated with the carious bone. It has a greyish, brown, or black colour, but the surrounding bone is highly vascular. Beyond and around the carious area, induration and hypertrophy may have taken place ; the circum- ferential substance of the bone being dense, and presenting externally osseous nodules or spicula, with thickening of the periosteum. In the substance of bone, the appearance of Caries is more marked in the cancellated structure, which is also more especially the seat of caries. The enlarged cancelli are filled Avith the detritus, and their walls are in a softened state ; the Avhole crumbles down under pressure with the finger, or may be readily penetrated by a probe, and yields with a grating sensation. This condition is commonly found in the articular extremity of a long bone; as that of the tibia or femur, in scrofulous disease of the knee-joint affecting either bone. On the surface of a bone, Caries presents a drilled, worm-eaten appearance (Fig. 148). The periosteum is loosened or detached, thickened, vascular and villous. The projections, thus formed, pass from the under sur- face of the periosteum in corresponding depressions in the bone, its compact structure having acquired more the open character of the cancellous. The textural condi- tion of the bone is similar to that already described as pertaining to deep caries. Superficial caries is, perhaps, more commonly seen in the cranial bones, and as result- ing from secondary syphilis. A somewhat significant resemblance exists betAveen the forms of syphilitic ulce- ration in bone and syphilitic eruption on the skin. Thus, Mr. Paget has described, annular or circular, reticulated, and tuberculated, ulcers of bone. But these various forms are more interesting pathologically, than diagnostic. The Signs of Caries, are the characters of carious bone, as just described. They are not declared until abscess having formed and discharged, the bone becomes exposed, or accessible. Superficial caries is more open to examination; but the introduction of a probe will readily discover the state of the bone, both in it and deep caries. Both forms of Caries, deep and superficial, are attended Avith pain, more or less deep-seated, redness and swelling of the integument; followed by suppuration and the formation of abscesses. The soft parts around then present the usual characters of increased swelling, fluctuation, and discoloration. Any such abscess bursting, dis- closes the carious state of the subjacent bone, or leads to a carious cavity, as discovered by a probe. Fistulous openings remain, dis- charging unhealthy pus mixed with the granular detritus of bone. (Fig. 149.) Large, outcropping, abortive granulations spring up; and the surrounding integument has a congested purplish appearance. Caries evinces little disposition to undergo any reparative changes. 492 SPECIAL PATHOLOGY AND SURGERY. Fig. 149. The Causes of Caries are those which produce inflammation of bone, especially as occurring under the influence of some constitutional condition. Scrofula and syphilis thus not uncommonly affect the bones, and in the form of Caries; the disease arising often, apparently, with- out any external occasion of injury as an exciting cause. Treatment.—The removal of any cause in operation is the primary rule of treatment in this, as in all other conditions of disease. Hence the reme- dial measures appropriate for Constitu- tional Syphilis or Scrofula, will be re- quisite, in most cases of Caries. Rest of the affected part is highly advan- tageous ; but any topical applications, as counter-irritation, by iodine, blisters, or issues, are useless, compared with constitutional treatment. In an early stage, the disease may thus be arrested and the bone restored to a healthy state. Or, under the influence of this treatment, disintegration proceeds only so far as to gradually remove the affected portion by a gritty discharge ; recovery then taking place by granulation. In a chronic state, the disease is beyond the power of restoration, and reparation is unable to discharge the carious portion of bone piecemeal. Operative interference, therefore, now becomes necessary. The dis- eased bone may be removed by excision, of either the affected portion only, or of the whole bone; or amputation may be unavoidable, owing to the extent of the disease, or after excision, as the last resource. Excision of the carious portion. This should always be a patient proceeding, never a "brilliant" operation. The bone haAung been exposed by a crucial incision, the diseased portion must be removed piecemeal by means of a gouge. Various forms of this instrument are used, according to circumstances. The ordinary scoop-gouge (Fig. 150) is generally most convenient; and the rose-head osteotrite Avill often prove very serviceable in finishing off a carious cavity. Care should be taken in working Avith a cutting- gouge, lest the instrument suddenly slip, and be driven accidentally into the soft parts. A steady, sIoav movement of the hand, and grasp of the instrument almost to the point, are the best precautions against any such misad- venture. The carious portion of bone yields to the gouge with a gritty resistance; whereas the sound bone remains firm, and vascular. The extent of bone to be removed may, therefore, be determined by these characters; por- tions of softened, crumbling bone should be scooped out, until the firm, rose-coloured bleeding bone is reached. The surface or cavity, having this healthy character, is then dressed or plugged lightly Avith wet lint, and the Fig. 150. NECROSIS. 493 Avound allowed to fill up and heal by granulation. In this way I have removed, more or less successfully, carious bone from nearly every bone. The whole rim of the spine of the scapula having been excised in one case, the patient—a lady of very delicate health—recovered slowly but soundly. In another case, I removed the whole of the middle third of the shaft of the tibia, excepting a shell of bone posteriorly. Granula- tions, healthy and abundant, sprang up, and nearly filled up the large cavity; but the patient by the rules of the hospital, as to time, left in- completely cured, and I do not know the result. The articular end of a bone—affected by Caries—may require exci- sion, as will be fully explained in treating of Diseases of the Joints. Excision of the whole bone is rendered necessary by an extent of disease beyond the range of either of the previous partial operations, in the shaft or articular end. Amputation is justifiable only as the last resource. The foot, for example, may be removed for carious disease involving the tarsal bones; or when excision has failed, Necrosis.—The death of a portion of bone is analogous to Mortifica- tion of the soft parts ; and it has the same pathological relation to Caries that Mortification has to Ulceration. Caries is molecular death or disin- tegration of the osseous texture ; Necrosis, the death of a visible portion or mass of bone. Structural Condition.—Necrosis—like Caries—may affect the sub- stance, or the surface, of a bone. In the one form of necrosis, the dead portion is named the sequestrum, a term more particularly applicable when the piece of bone is loose and enclosed by new bone; and when limited to the deepest portion of bone around the medullary canal, this is sometimes named central necrosis; while, in the other form, a superficial scale-like portion of dead bone is designated an exfoliation. Necrosed or dead bone, is rough, hard and white; becoming brown or black when exposed to the action of decomposing pus and the air, from sloughing of the integument. It is avascular, not yielding any blood when wounded, and insensible. The whole substance of a bone, or its central portion only, may be in this state; in point of extent also, the whole length of the shaft of a long bone is sometimes necrosed, and occasionally, even the epiphyses are involved. But, the periosteum, at first adherent, soon loosens its con- nexion with the subjacent dead bone, and deposits ossific lymph between itself and the surface of the bone. This deposit undergoing ossification, forms a sheath of new bone over or around the dead portion, which thus becomes enclosed in an osseous sheath. The periosteum is the chief, but not the only source of osseous reproduction in necrosis. Respecting this vexed question ; observation has shown that the original bone itself is an important source of new bone—by granulation—in the absence of the periosteal membrane, or in central necrosis ; and that the medullary membrane may contribute its share. The articular ends, in particular, evince a remarkable ossific power, when the shaft of a long bone is removed. Apart from the osseous texture and medullary membrane ; the soft tissues around the bone may also acquire the power of forming ossific deposit. The dead portion, at first continuous with the healthy bone, loses its connexion at the line of continuity; the living bone detaching itself from the dead. Ulceration takes place in the course of that line, and forms a groove around the junction of the dead portion of 494 SPECIAL PATHOLOGY AND SURGERY. bone ; this groove deepening, at length completely detaches it. This twofold process goes on simultaneously, though not perhaps equally ; constituting a separation of the living from the dead bone, and reparation chiefly by the periosteal reproduction of a sheath of new bone enclosing the dead portion. Both changes are sloAvly progressive. But at length, the sequestrum becomes complete and ensheathed. Exfoliation, or superficial necrosis, presents the same appearances as to the state of the dead portion of bone. But, it results generally from the destruction of the periosteum ; consequently, no periosteal sheath of new bone is produced. The plate of dead bone is detached—as in deep necrosis—by linear ulceration forming a groove circumferentially ; but, the detached portion not being ensheathed by new bone, it is thrown off from the surface or exfoliated, and exposed by open abscesses or slough- ing ; or it can be easily removed surgically by forceps. The periosteum of the cranial bones, even when uninjured, does not seem to have the power of forming a sheath of new bone ; and thence the same result ensues— exfoliation. The Signs of Necrosis are, the characters of necrosed bone, as already described. But—as Avith Caries—these characters are not declared until abscess having formed and discharged, the bone becomes exposed or accessible. Exfoliation is more open to examination ; and the introduc- tion of a stout probe will readily discover the rough, loose sequestrum; or, when visible, it may be recognised by its dead Avhite appearance. Necrosis is attended with violent and deep-seated pain, considerable redness and swelling of the surrounding soft parts. Suppuration ensues sooner or later, in consequence of inflammation of the bone—ostitis, having led to and being connected with the necrosis, or as the result of prolonged irritation of the sequestrum—itself a foreign body. Pus collects around the sequestrum, and interrupting the complete formation of the periosteal sheath of new bone, leaves apertures therein, named cloaca; through which, sinuous tracks between the sequestrum and fistulous openings in the integument, become established. Thus is pre- sented the structural condition of necrosis, commonly seen. (See Fig. 149.) Unlike Caries, this condition occurs more frequently in the shafts, than in the articular ends, of long bones; and usually in the compact, rather than the cancellated, structure of any bone. Central necrosis is necessarily more obscure, owing to the depth of the morbid condition. The symptoms resemble those of chronic abscess in the substance of bone. Deep-seated and, perhaps, throbbing pain, with some swelling of the bone, or puffiness over a particular spot; are the more characteristic symptoms, and their persistence is even more sig- nificant. Causes.—External and traumatic causes seem to have a more absolute effect in producing necrosis, unaided by any predisposing constitutional influence, than in relation to caries. Any injury detaching the periosteum, will probably be followed by more or less necrosis ; excepting in the cranial bones, or others which are highly vascular. Violent contusion may so damage the osseous texture and medullary membrane, as to pro- duce necrosis. Severe cold, as in frost-bite, and deep burns, are also immediate causes. Powerful irritants have a marked effect, apart from any inflammatory action. Thus, the fumes of phosphorus, in lucifer- match manufactories, often produce necrosis of the lower jaw ; this powerful irritant entering the bone, apparently, through carious teeth. NECROSIS. 495 Any condition of inflammation of bone—ostitis, periostitis, or osteo-mye- litis—may also induce necrosis. Constitutional causes are very influential ; sometimes predisposing only, or frequently producing, necrosis. Scrofula, syphilis, and formerly, the excessive administration of mercury, represent this class of causes; but necrosis occasionally, results from typhoid fever and other exhausting diseases. Consequences.—Continued suppuration accompanies necrosis, and in proportion to its extent. The matter burrows among surrounding muscles, and disorganizes the whole substance of the part; while the numerous sinuses opening externally and communicating with the bone, continue to discharge an unhealthy pus. Large, protuberant granulations, springing up around the orifices of these passages, evince an abortive tendency to close up the soft parts ; but reparation of the bone, by the formation of a periosteal sheath, is far more active. The ulcerative detachment of the dead portion of bone, sometimes extends to a large vessel, or the point of the sequestrum may be driven into an artery in some movement of the limb ; giving rise to serious haemorrhage externally, or the formation of aneurism. But these perilous consequences are rare. Haemorrhage from ulceration, occurred in a case of necrosis of the femur Avhich thus involved the popliteal artery, as shown by Dr. Porter in the " Dublin Journal," vol. v.; and in two other cases the artery was wounded by a sequestrum during active movements of the limb : one of Avhich is related by Dr. Byron in the " Med.-Chir. Rev.," vol. xxiv., and the other by Dr. Jacob, in his "Diss. Med.-Chir. de Aneurismo," Edin., 1814. Mr. Stanley men- tions a case in which the capsule of the knee-joint was penetrated by the pointed end of the necrosed shaft of the femur. Mr. Holmes has seen fatal haemorrhage from the lingual artery in disease of the jaw, the nature of which is not stated; and from the aorta in caries of the spine. Treatment.—The removal of any cause in operation, must be the primary consideration. Traumatic causes, which have already expended their force, so to speak, in producing necrosis, are obviously not under control. But, as arising from detachment of the periosteum, exfoliation may sometimes be prevented by timely replacement of this vascular membrane; or if adhesion takes place between the bone and adjoining soft parts, or granulations spring up from the surface of the bone, a new periosteum will be gradually formed. Constitutional causes cannot be altogether overcome, but their full effect may be prevented. Hence, the medicinal treatment appropriate for scrofula, or constitutional syphilis, proves very beneficial in most cases. Suppuration and abscess must be treated on ordinary principles ; while the accompanying hectic and constitutional irritation of dead bone, should be supported by a tonic and stimulant plan of treatment with nourishing diet. Extraction of the sequestmm.—The dead portion of bone is a foreign body. Unless, therefore, it be throAvn off by Nature, it must be removed by Art. Its removal is determined, both in point of time and the extent of dead bone to be removed, by the ulcerative line of demarcation and the detachment of that portion; a process of some weeks' or months' duration, and the progress of which should be ascertained, from time to time, by examination with the probe. A loosened sequestrum, imprisoned 496 SPECIAL PATHOLOGY AND SURGERY. within a sheath of new bone, can only be extricated by surgical inter- ference. The operation consists in cutting down upon the bone, and extracting the sequestrum, by means of serrated bone-forceps. (Fig. 151.) In making the incision, advantage is taken of the course of the fistulous tracks leading to the cloacae in the bony case ; and then the latter aper- tures are made available for removal of the sequestrum. Sometimes, one of the cloacae is sufficiently large to alloAV of the extraction of the seques- trum through it. Or the cloacae may be enlarged, or two apertures thrown into one by excising the intervening portion of the bony case, with strong-cutting pliers, straight, or angular bladed. (Figs. 152, 153.) Or again, it may be more convenient to divide the sequestrum by the same instrument, and extract either fragment separately. The removal of any portion of the bony case, is undesirable, as the new bone is not reproduced, and the limb, therefore, remains proportionately weakened. Fig. 153. Fig. 151. Fig. 152. 7 Haemorrhage occurs freely during this ope- rative procedure; the blood springing from the vascular soft parts around, or Avelling up from the new bone. But, it can generally be arrested by pres- sure. The bottom of the wound should be lightly dressed with lint; any inflammation consequent on the operation must be subdued by ordinary treatment; and eventually the limb should be supported by a starched ban- dage until granulation is complete and the bony case has acquired sufficient strength, to bear the weight of the body or the movements of the part. I have thus, from time to time, removed several loose sequestra from the lower half of the shaft of a femur; guided by the sinuses, and preserving the os- seous case which had formed around the bone. In a compound fracture of the tibia with detachment of the periosteum ; the end of the upper fragment to an inch and a half in extent, separated as a sequestrum, which I re- moved, together with several small scaly and spiculous portions from the lower fragment. Union ensued, but imperfect consolidation; a slight hinge-like mobility remaining for some months. An exfoliation may be RACHITIS OR RICKETS. 497 thrown off naturally; but this process will be much facilitated surgically by incisions, Avheu the dead portion has separated. Excision of the whole of the bone necrosed, or short of its articular end.—This operation may, occasionally, be had recourse to in extensive necrosis. Thus, the lower jaAV has not unfrequently been removed for necrosis caused by the fumes of phosphorus. The entire shaft of the radius, leaving its articular ends, was excised by Mr. Savory, on account of necrosis; and afterwards, the bone Avas reproduced from either end to such an extent, that in eight months there remained an interval of only Fig. 154. an inch and a half, and this appeared to be gradually diminishing. The fibula also has been excised. Removal of the ungual phalanx of a finger, for necrosis from whitlo, has proved perfectly successful in preserving the end of the finger. These results are sufficient, to encourage the practice of excision in other cases of extensive necrosis. In operations for bone-excision, in necrosis, as of the lower-jaAv ; a short, narrow- bladed saw will often be found very convenient. (Fig. 154.) Amputation must be regarded as an extreme resource, but justifiable as a sacrifice of the limb for the preservation of life. In necrosis involv- ing the neighbouring joints ; or where the limb has become disorganized by prolonged and profuse suppuration; or the general health undermined by hectic ; amputation is unavoidable. Thus, in a case of necrosis of the femur consequent on typhoid fever in India, the whole shaft of the bone Avas involved, the limb enormously thickened, and the muscles were matted together. I amputated the limb close to the trochanter, and the patient made an excellent recovery, regaining his general health. And in the more rare cases, also, where a main artery is opened by ulceration, or wounded by the sequestrum; amputation will generally be preferable to ligature of the vessel, in situ, or of the main trunk. Rachitis or Rickets.. — Structural condition. — This disease affects more or less the Avhole osseous system. The earthy matter of the bones is diminished, and the organic basis, therefore, proportionately increased; the cancelli are enlarged and filled with a brownish-red fluid. Bones in this state have acquired great softness and flexibility, thence undergoing remarkable changes of shape, in consequence of the Aveight of the body, or other forces to which they are subject. The bones of the limbs in particular become curved and distorted, the pelvis collapsed and twisted, the thorax contracted above and enlarged loAver down by the dragging Aveight of the abdominal viscera, and the spine often undergoes lateral curvature. The cranium appears enlarged, owing perhaps to the imper- fect development of the facial bones; presenting a large head and dimi- nutive face. The Signs of rickets are some of these peculiar deformities of the osseous system. They occur also in connexion Avith manifestations of scrofula. The Causes of this disease are obscure. It would appear to be a condition of imperfect formation of the osseous texture; rickets never K K 498 SPECIAL PATHOLOGY AND SURGERY. arising after the bones have become fully ossified and consolidated ; nor, indeed, after the age of puberty. It is a disease of childhood or infancy, and possibly commencing in foetal life ; although its results remain in the adult. . . Termination.—The bones become strengthened by osseous deposit in the parts most requiring support; the long bones acquiring increased thickness in their small curvatures, and the deposition extending even into the interior, so as to partially obliterate the medullary canal. Treatment.—The primary indication obviously is, to supply the de- ficient earthy matter ; and so, probably, arrest the disease. But no known medicinal preparation seems to have this effect. The phosphates of lime, or lime-water, have been administered; but in several instances I tried them without any perceptible result. Iron and quinine combined, often prove more beneficial. These medicinal tonics, Avith due regulation of the bowels, nutritious diet, pure air, sea-bathing, frictions, and other means for improving the general health; constitute the most effectual plan of treatment. Daily exercise may be taken advantageously; but the bones of the lower limbs should be relieved from the weight of the body, by the patient reclining at intervals during the day, and wearing steel-supports so applied as to resist any tendency to curvature. Many a little, scrofulous child—pot-bellied and bandy-legged, may thus be reared to man's estate; when Nature will complete the cure. Mollities Ossium—Osteomalacia—Malacosteon.;—Structural con- dition.—This diseased state of the bones is far more rare than rickets, only a few instances having been recorded ; but it is also far more serious. The earthy matter is greatly diminished, but replaced by a peculiar red- dish gelatinous matter, chiefly fatty, and containing nucleolated nuclear cells, which have been described by Mr. Dalrymple. This matter occupies the cancelli, which are considerably enlarged, and cavities in the compact texture ; infiltrating the whole substance of the bone, until, as Dr. Ormerod remarks, it more resembles fatty matter enclosed in a periosteum than a bone. Bones thus affected, are soft and flexible; on section, the osseous texture yields a gritty sensation, and has a reddish-brown or maroon colour, exhibiting the peculiar gelatinous matter in an extremely rarefied osseous texture. The chemical composi- tion of bone in this state—according to Dr. Leeson's analysis—is; in 100 parts—18-75 animal matter, 29-17 phosphate and carbonate of lime, and 52-08 water. Commencing, apparently, in the cancellous tissue, the compact portion may retain its natural consistence, as an outer shell of bone; and the whole length of a long bone may not be affected. But many bones are always simultaneously diseased. Fracture, or bending without fracture, ensues, according to the extent of the disease. When softening is limited to the internal part of the bones affected, leaving an outer shell of hard bone, fracture is liable to occur; in one case, related by Tyrrell, 22 frac- tures happened; in another, by Arnott, 31 fractures. When the disease involves the whole thickness of the bones, they become bent in various forms, and to an extreme degree; presenting the most remarkable and frightful deformities. For example, the thighs have been bent, until the feet touched the head. Mollities ossium and Rickets have some structural characters in common; the marked diminution of earthy matter, and rarefaction of the osseous texture ; both diseases also affect more or less the osseous RACHITIS OR RICKETS. 499 system generally. But the gelatinous matter is peculiar to mollities ossium. In respect of its fatty character, the disease has some affinity to fatty degeneration ; while, in virtue of the nuclear and nucleated cells, a few of which may be caudate-shaped, there would appear to be some alliance to the structural elements of Cancer. Signs and Symptoms.—Certain premonitory symptoms, usually, pre- cede fracture or deformity from mollities ossium. Wandering pains in the affected bones are experienced, and of a rheumatic character, but more severe and persistent. Marked failure of the general health accom- panies these osseous pains; while great exhaustion and some emaciation precede any perceptible change in the bones. Then a fracture here or there, and progressive deformity, leave scarcely any doubt as to the nature of the disease. Diagnosis.—From Rheumatism, it is at once diagnosed by these mani- festations of morbid osseous condition; from Cancer, by the very general distribution of the disease, affecting more or less the whole osseous system, and by the deformity. Thus, according to Litzmann, in 85 child-bearing women, the Avhole skeleton was affected in 6 cases, and all the bones except those of the head in 2; and in 46 other cases, all parts of the skeleton were diseased in 21, and all the bones except those of the head in 6. From Rickets, as Avell as other diseases, Mollities Ossium may be distinguished by another symptom. The state of the urine is peculiar. It contains a great abundance of earthy matter, which was shown by Mr. Solly to be phosphate of lime, removed from the bones and eliminated through the kidnejrs. But the urine may also contain a peculiar substance, nearly allied to albumen, and in great abundance. According to the analysis of Dr. Bence Jones, in Mr. Dalrymple's case, this substance is the hydrated deutoxide of albumen, and that 6697 parts Avere passing out of the body in every 1000 parts of urine. Here, therefore, there Avas as much of this albuminous substance in the urine, as there is of ordinary albumen in healthy blood; an ounce of urine passed Avas equivalent to an ounce of blood lost, as regards its albumen. '' The peculiar characteristic of this hydrated deutoxide of albumen was its solubility in boiling water, and the precipitate Avith nitric acid being dissolved by heat and reformed when cold. By this reaction a similar substance in small quantity may be detected in pus, and in the secretion from the vesiculae seminales. The reddening of the urine on the addition of nitric acid might perhaps lead to the re-discovery of this substance; Avhen found, the presence of chlorine in the urine, of Avhich there Avas a suspicion in the above case, should be a special subject of investigation, as it may lead not only to the explanation of the formation of the albuminous substance, but to the comprehension of the nature of the disease Avhich affects the bones." Causes.—The pathological cause of mollities ossium is unknoAvn. But the disease in no Avay arises from an imperfect formation of the osseous texture, and does not generally occur before the middle period of life, or subsequently; thus, also, differing from rickets. It Avould appear to be hereditary, in some cases. Females are more subject than males, and repeated pregnancy seems to engender a predisposing con- dition. Termination.—The fractured bones evince little or no tendency to the formation of callus; and as the deformity resulting from their bend- ing increases, the patient becomes a Avretched cripple, yet living perhaps for years. Ultimately, death ensues from sheer exhaustion ; or, func- kk 2 500 SPECIAL PATHOLOGY AND SURGERY. tional disturbance, consequent on altered relations of the viscera or pressure from deformity, proves fatal. Treatment.—No known medicinal agents have any curative efficacy. A generally tonic and nourishing plan of treatment may someAvhat relieve the concomitant exhaustion of mollities ossium, and opiates alleviate the wearing pains. Posture, and mechanical contrivances, are also of some use in counteracting the progressive deformity, and render- ing life more tolerable to the patient, Avhen bedridden. Fragilitas Ossium.—Brittleness of the bones is, pathologically, the opposite condition to Rickets; implying a superabundance of earthy matter in their composition. Occurring as a natural change in the bones as life advances; it may also, at other periods, be symptomatic of cancer, syphilis, scurvy; and, probably, of other diseases of, or affecting, the osseous system. Tumours of Bone. Exostosis.—Structured Condition.—Exostosis is an out-growth of bone, its texture therefore resembles either the compact or the cancellated structure of bone. The compact variety, consisting of solid bone, is of small size, and is very hard—hence named irory-exostosis. It is commonly situated on the flat bones, especially the cranium. This A'ariety of exostosis—ob- serves Mr. Paget—occurs in tAvo forms. Some grow on the exterior of the bones of the skull, in smooth, spheroidal, or lens-shaped lumps, attached, commonly, by rather narrow bases. Others, which are usually of deeply lobed and nodular shapes, grow in the diploe, or the frontal or other sinuses, whence, as they enlarge, they project through the gra- dually thinned and perforated layers of bones that at first enclosed them. The former kind rarely increase to an inch in diameter ; the latter may increase to many inches, and they commonly project into the cavity of the skull, as well as externally, or into the cavities of the orbits or any other adjacent parts. The cancellous variety, consisting of the open medullary texture of bone, containing marrow, and invested Avith a very thin layer of com- pact tissue, is of considerable size, and yields somewhat under pressure. It is commonly situated on the shaft of a long bone ; particularly the femur, on its inner surface, just above the condyle; the head of' the tibia; or phalanges of the fingers or toes. Another very common situa- tion—according to Mr. Holmes' observations—is beneath the deltoid muscle : but here I have never met with the cancellous variety of exostosis. In both conditions, the structure of exostosis usually resembles that of the bones on which they, severally, grow. Exostosis generally occurs singly; but many may form, when they are usually symmetrical. This is particularly observed in the cancellous variety. Signs.—The characters of exostosis are sufficiently obvious; a very hard, or a somewhat yielding, rather pedunculated tumour, immovable or nearly so; attached to the bone as an out-growth. Causes.—The compact variety is attributed to syphilis, scrofula, or other diseases affecting bone, and which produce an out-growing hypertrophy of the compact osseous texture. The cancellous variety results from the ossification of an enchondromatous or cartilaginous tumour. It may, therefore, be said to be developed through cartilage ; TUMOURS OF BONE. 501 while the ivory variety is rarely so produced. Age seems to have some causative relation to exostosis; both varieties commencing, probably, in earliest infancy. Course and Terminations.—Both forms of exostosis are sloAv-groAving, and particularly the compact variety; but the cancellous attains a far larger size. Both may undergo certain destructive changes; necrosis, or sloughing aAvay from the bone, and occasion ulceration of the super- imposed integument. Both also may occasion various functional distur- bances by pressure. The situation of exostosis Avill very much determine these results. Thus, an ivory exostosis has projected into the orbit; or growing from the inner table of the skull has pressed upon the brain; or, from the pubic bone, has perforated the bladder. Treatment.—Exostoses which remain stationary, or occur in certain situations, as the orbit, are better left alone. The danger also of ex- posing cancellated bone, should always be considered; diffuse suppuration and pyaemia being very liable to folloAv the operation of removal. Other- wise, an exostosis may be removed mechanically, by excision ; or destroyed, by nitric acid or other strong caustic, applied to its exposed base. Compact or ivory exostosis is often very difficult of excision. Several instruments should be provided ; that one failing, another may proAre efficient. A trephine, saw, chisel and mallet, or cutting pliers, are some- times severally requisite to remove the little ivory-hurd lump of bone. They all, in turn, failed in the hands of an expert operator—the late Mr. Keate—although employed perseveringly for nearly tAvo hours. The exostosis having been removed down to its base, caustic may then be applied to destroy the remaining portion by exfoliation. Potassa fusa and nitric acid were thus applied successfully in Mr. Keate's case. Exostoses do not recur after removal; and, fortunately, even when the base of attachment is left, the tumour is not likely to grow again. Enchondroma. — In connexion Avith bone, enchondroma or cartilagi- nous tumour has already been considered, as being the most promi- nent part of the general pathology of this species of Morbid Growth (Chapter ii.); for it occurs principally in connexion with the osseous system. Enchondroma—or, occasionally, some other kind of groAvth— may be contained in the centre of a bone, and surrounded by an osseous shell or bony cyst; it is then sometimes designated "bullous exostosis," especially by French Surgical authors. Treatment.—Excision or amputation will be appropriate, according to the size and relations of the tumour. Fibrous Tumour.—The formation of a fibrous tumour in connexion with bone is far more rare than the cartilaginous tumour. It is, how- ever, illustrated by epulis and fibrous nasal polypus; both of Avhich are fibrous out-growths. The Signs of any such tumour much resemble those of enchondroma; and their diagnosis is unimportant. The Treatment is excision or amputation. Cysts.—Two kinds of cysts have been found, in bone ; the serous and sanguineous. Their pathology for the most part merges in the general history of these cysts (p. 85). They are multilocular, the cavities often communicating; and they are met Avith in the jaws or in the long bones —their shafts or articular ends. They groAv to a large size, that of a cocoa-nut or foetal head. Unilocular cysts are also described by Nelaton as containing solid matter, of a fibrous or fibro-cartilaginous structure, 502 SPECIAL PATHOLOGY AND SURGERY. occupying entirely the cavity of the cyst. These are found in the same situations as the last, but grow to a less size. Cysts in bone occur mostly in adults. Signs.—They produce an expansion of the surrounding osseous tex- ture, and at length being enclosed in a thin lamellar capsule of bone, yield a crackling sensation under pressure with the finger and a deeper or more obscure elasticity or semi-fluctuation. Perforation here and there taking place by progressive absorption of the lamellar capsule, the enclosed tumour becomes more clearly perceptible. The superimposed skin yields before the increasing tumour; but without discoloration or any participation in the disease, and there is little or no accompanying pain. The tumour is thus plainly non-malignant in its development. Treatment.—Fluid cysts may be laid open by removing a portion of the bone, by trephining or otherwise, and the cavity dressed from the bottom with lint. Granulation will then obliterate the cyst. Solid cysts must be excised, or recourse had to amputation ; according to the size and relations of the cyst. Cystic Tumours.—In bone, as in other parts, tumours occur, contain- ing cysts. Fibro-cystic tumour of bone commences, apparently, in the cancellous tissue, and growing outwards, occasions fracture. The Signs are those of cysts in bone; an elastic sensation or obscure fluctuation. The femur was the seat of the disease in four cases, one of which is related by M. J. Adams in the " Path. Soc. Trans.," vol. v., and the remaining three by Mr. Prescott Hewett, are appended to the report of that case. The absence of pain, integumental discoloration, and glandular SAvelling; distinguish this tumour and other innocent cystic tumours from Cancer. Amputation was followed by permanent recovery in the above cases. Hydatid-cysts in bone, are interesting chiefly in relation to the fluid cysts, above described. The entozoon has been in all cases, the echino- coccus or acephalocyst; except in one case, mentioned by Mr. Stanley, where the cysticercus cellulosse was found in the interior of one of the phalanges. But hydatid-cysts are very rare ; eight cases only being re- ferred to in Rokitansky's work; to which a limited number of instances might be added. These cysts may be seated in a flat bone, as the skull or ilium, or in the expanded head of one or more of the long bones; cases of which are cited by Mr. Holmes. The diagnosis with reference to ordinary fluid cysts, can scarcely be drawn. The cysts increasing in size, fracture occurs, as probably the first appreciable sign; and the bone remains ununited. This, however, is incident to other diseases of bone. A discharge of fluid containing entozoa would determine any question of diagnosis. This may occur spontaneously, or be obtained by puncture. The treatment, also, is the same as for ordinary fluid cysts; but it will be advisable to destroy the interior of the hydatid cyst by freely applying nitrate of silver or other caustic. Recurring Tumours of Bone.—The Myeloid form of Enchondroma, in connexion Avith bone, is sufficiently described in the general pathology and treatment of this groAvth. Recurring osteoid tumour is illustrated by a series of three prepara- tions in the Museum of the Royal College of Surgeons, to the remarkable history of which Mr. Holmes has called attention. A hard, and heavy, dry osseous substance formed around the ends of the femur and tibia, projecting into the knee-joint, extending far up the thigh and implicating TUMOURS OF BONE. 503 the popliteal artery, vein, and nerve, so as to cause oedema and severe pain. (Prep. No. 3244.) Amputation was performed at the thigh. The patient remained well for five years ; then another osteoid tumour formed on the stump of the femur, accompanied with severe pain. Amputation was performed higher up. The tumour appeared to grow, not from the bone itself so much as from the periosteum, and enclosed the femoral artery. (Prep. No. 3245.) An interval of health again continued for two years; Avhen another tumour formed about the stump, progressed up- wards, out of reach of operation, and finally proved fatal, by inflamma- tion and sloughing of its soft coverings, twenty-five years after the first appearance of the disease. The general health of the patient, a male, remained una'ffected during the whole period. (Prep. No. 3245a.) Another, and very similar case, may be found in Mr. Paget's Surgical Pathology. These cases of recurring osteoid tumours, certainly bear a remarkable analogy, in their course and tendency, to the recurring fibroid and fibro- nucleated tumours—varieties of fibrous tumour. Cancer.—Each species of Cancer—encephaloid, scirrhous, colloid, and epithelial cancer, is liable to form in connexion with bone; but encepha- loid is the most frequent. Like other diseases of bone, Cancer may affect the substance or the surface of a bone; in the one situation, it is known as interstitial or possibly central cancer, in the other, as periosteal cancer. In the substance of bone, interstitial cancer occurs in the form of scat- tered nodules, having a Avhitish colour, and the consistence of scirrhous, or hard encephaloid cancer. The cancer-cell—so little absolutely charac- teristic of cancer—may be indistinguishable or absent. These nodules coalescing, form a mass, which occupies the cancellous tissue, and extends into the medullary canal. The bone surrounding such a formation is expanded and thinned or thickened; with osseous fibres traversing the substance of the tumour, radiating from its centre. It is situated most commonly, in the articular ends of a long bone, or in a flat bone, as the pelvis or skull. As affecting the whole bone, this condition of the disease is sometimes designated, infiltrated cancer of bone. On the surface of bone, periosteal cancer forms between the bone and periosteum ; rarely involving the one, while the other may sometimes be traced over the tumour. Osseous fibres radiate from the surface of the bone through the tumour; and a bony deposit forming a coral-like mass, often spreads around it. Periosteal cancer appears, usually, in the long bones, especially affecting their articular ends. The incrusting cartilage of the contiguous joint generally escapes, in both this, and the interstitial formation of cancer; although the disease may extend to the capsule. Osteoid cancer is a term used to designate a further degree of ossifica- tion, than that commonly met with in interstitial and periosteal cancer- groAvths. This is analogous to the ossification of enchondromatous or cartilaginous, and fibrous, tumours. Osteoid cancer is described by Mr. C. H. Moore as being, in a Avell-marked case of the primary tumour, a large mass of the hardest enamel or ivory-like bone; the glandular disease is bony, though it may be less hard ; and the disease disseminated in the soft internal organs, and protruding into the blood-vessels, is also in great part, osseous. Any bone is liable to cancer-formation ; but some are far more so than others. The femur and tibia are most subject to the disease, and par- ticularly the articular ends of these bones at the knee-joint. Thus, of 20 cases of cancer of the long bones of the lower limb, 11 were situated near 504 SPECIAL PATHOLOGY AND SURGERY. this joint. The pelvis, spine, skull—especially the antrum and the humerus—are also seats of cancer. Signs, and Diagnosis.—(1) Cancer in the substance of bone, produces expansion and an osseous tumour; but the nature of this tumour can scarcely be recognised at first. The enclosed encephaloid cancer is much harder than when this disease affects the soft parts. At length, the enclosing shell of bone yields, and the mass declares itself at once, or very shortly, as the tumour unrestrained, groAvs more rapidly. The ordinary characters of an encephaloid tumour become apparent ; its soft con- sistence, lobulated contour, and large size; Avith purple discoloration of the skin, enlarged, ramifying veins, and pain throughout the course of the disease. Pulsation, of a thrilling or blowing character, may become per- ceptible, owing to enlargement of the vessels in the tumour, as it under- goes development. Fracture often occurs at the affected part. Glandular swellings and constitutional symptoms will confirm the diagnosis. (2) Periosteal cancer presents a tumour of more clearly cancerous character, and it grows more rapidly, at an earlier period. The muscles attached to the bone often become extensively infiltrated Avith cancer- cells. Thus may Cancer in, or on, bone, be recognised and distinguished from any other species of tumour. The diagnosis of malignant and non- malignant tumour of bone, lies, however, principally between encephaloid cancer and enchondroma. Here the presence, or absence, ultimately, of the signs Avhich indicate an extension of the disease to the integument and neighbouring lymphatic glands, will mainly determine the question. Puncture with a grooved needle is also available as a critical method of examination, in this case, no less than in other doubtful forms of tumour. I Avas thus enabled to determine the nature of a tumour at the lower end of the femur close to the knee-joint; which in point of consistence and lobulated appearance, much resembled enchondroma. Amputation was performed, and the mass proAred to be encephaloid. Pulsating encephaloid may be distinguished from aneurism by the expansive, heaving character of the latter, as compared Avith the thrilling vibration of the former. Treatment.—Excision will be appropriate only in cases of limited cancer-growth in, or on, bone; and when situated Avhere the whole diseased portion can thus be removed. But under, apparently, the most favourable circumstances of limitation, the operation itself may prove most perilous. I once assisted my colleague, Mr. De Meric, in removing an, apparently, moveable tumour, the size of a small orange, and situated over one of the mid-ribs. But this little mass sprang from the bone, the rib readily broke, and the Avelling up of blood from the tumour—an encephaloid cancer—was so profuse, that the patient nearly died on the spot. He sank in a few days from haemorrhage into the pleura. Amputation must generally be resorted to. This operation should be performed in the earliest recognised condition of the disease, and certainly before any enlargement of the lymphatic glands has evinced the super- vention of systemic infection. Moreover, removal by amputation can only be effectual for the prevention of the recurrence of cancer, when the operation is performed high above the part affected so as to be entirely free of the seat of the disease. Hence, in interstitial cancer of bone, the line of amputation should be—not in the continuity of the bone—but above the next joint; and in periosteal cancer the line will -be most DISEASES OF PARTICULAR BONES. 5l)5 judiciously selected even higher up, above the origins of the muscles infiltrated probably by proximity to the disease. Pulsatile tumour of bone, and Osteo-aneurism.—Structural Con- ditions.—A pulsating tumour in, or on, bone, may be—(1) a tumour, not itself pulsating, but in connexion with an artery Avhich communicates its pulsations thereto; as, an enchondromatous, fibrous, or other turuour, thus connected ; (2) a vascular tumour; usually cancerous, and particu- larly, encephaloid in the course of its development; (3) a vascular growth or erectile tumour of bone, resembling aneurism by anastomosis in the soft parts, and constituting osteo-aneurism. This last condition is very rare, if it exist at all; and the best authorities, such as Cruveilhier and Rokitansky are agreed respecting the rarity of osteo-aneurism, and that most pulsating tumours of bone are highly vascular encephaloid tumours. The situation of any such tumour is generally the cancellous interior of a bone, especially of the long bones, at their articular ends; as the femur, tibia, humerus, radius ; also in the flat bones; as those of the pelvis and skull, and in the ribs. Signs, and Diagnosis.—An enlargement of the bone, with a thrilling- pulsation and bruit, are symptoms common alike to a highly vascular tumour, such as advanced encephaloid cancer, or aneurism by anastomosis. And, this pulsation subsides on compressing the main artery of the limb. But the persistence of a tumour, and its incompressibility, would be dis- tinctive of a mass having formed independent of the blood-vessels, a vas- cular tumour, and not a Avascular growth or enlarged congeries of vessels. The bony case, however, which encloses any such tumour renders this test inapplicable, until the bone yields and the mass protrudes on the surface of the bone. Or, compression of a main artery may be impracticable, owing to the situation of the tumour, as in the pelvic bones. Or again, the supply of blood may come from so many arterial branches, that it cannot be arrested by compression. A tumour pulsating in connexion with an artery is also distinguished in like manner. Subsequently, the nature of the tumour will be still further declared by its more developed characters; encephaloid cancer, for example, en- larges rapidly, and involves the skin and lymphatic glands. Treatment.—Having due regard to the almost exclusive cancerous nature of pulsating tumour of bone ; excision must have the same re- stricted applicability as Avith regard to cancer of bone in general. This operation has failed in cases of cranial and scapular pulsating tumours. Amputation is the only justifiable operation of removal, in other than the feAv exceptional cases alluded to. The more decidedly encephaloid the disease, the more appropriate will be this more SAveeping operation. It should be performed as soon as the nature of the disease is declared, and the line of amputation be chosen above the joint nearest to the bone affected. Ligature of the main artery leading to the part is said to have proved successful in some cases; but probably not in pulsating tumour of bone having an encephaloid character. Compression might be tried previous to ligature. Diseases of Particular Bones.—Cranial Bones.—Caries and Ne- crosis of these bones are liable to occur, as one of the local manifestations of Scrofula or of Syphilis. Commonly affecting the arch of the skull, and particularly the frontal bone; the ethmoid and sphenoid bones do not escape. The temporal bone seems specially prone to scrofulous caries. The structural condition, and signs, are both described under the 506 SPECIAL PATHOLOGY AND SURGERY. general pathology of Caries as affecting the surface of Bone, and of Scro- fulous and Syphilitic Ostitis, and exfoliation. The causes, most frequently constitutional, are sometimes traumatic; as exfoliation resulting from a contused wound of the scalp, or other in- juries of the head. The course of either state of disease is important Avith reference to tli9 probability of cerebral complications ; meningitis with effusion, convulsions and coma, being apt to supervene and terminate fatally Caries of the petrous portion of the temporal bone, as a form of Scrofulous disease, is more particularly dangerous. Ear-ache with chronic suppuration leads to perforation of the tympanum; the ossicula crumble, loosen, and are washed out by a profuse foetid discharge, exposing the dura mater con- tinuous with the cavities of the ear. If the disease be not fatal, permanent deafness results. Treatment.—The local measures for the removal of carious or necrosed portions of bone by operative interference, and the constitutional treat- ment of Scrofula or Syphilis, are in no way peculiar to the Cranial Bones. Diseases of the Jaavs will be considered, under this title, in connexion with Diseases pertaining to the Head. Diseases of the Spine.—See Spine. JOINTS. CHAPTER XXXII. INJURIES.--SPRAINS.--WOUNDS.--DISLOCATIONS. Sprains or Strains of the Ligaments of Joints.—These lesions essen- tially resemble similar injury of Tendons [ch. xx.]. The ankle or wrist- joint is most commonly affected. Severe pain, possibly inducing syncope, is soon followed by SAvelling around the joint; succeeded by stiffness, and continued inability to use the joint. A very severe sprain, or its repeti- tion, may leave the joint in a state of permanent weakness, and liability to dislocation. Or disease of the joint may ensue, in persons predisposed by any constitutional condition, as a rheumatic or gout diathesis. And it Avould seem that injury to a joint so alters its structural condition as possibly to induce disease under favourable circumstances; and perhaps after the lapse of a considerable period. Thus, Sir B. Brodie, shortly before his death, I believe, suffered from a malignant tumour of the shoulder, which was, apparently, referable to some textural disorganization consequent on dislocation of the joint some years previously. The cause of sprain, is a violent and sudden twist or wrench of a joint, whereby the opposing ligaments are stretched or somewhat ruptured. The treatment consists in an easy position and rest, warm or cold applications, according to the inflammatory character of the swelling and the feelings of the patient; followed by stimulating embrocations, and the support of a bandage, broad strips of plaster, or a starched bandage. Wounds of Joints.—A wound extending into a joint may, like other Wounds, be incised, punctured, contused, or lacerated; and the joint, WOUNDS OF JOINTS. 507 accordingly, is more or less opened, or extensively injured. But, the admission of air into the joint chiefly determines the importance of any such lesion; and thus the pathological condition of these different wounds must be estimated by this consideration. The extent of the synovial membrane, or the size of the joint should also be taken into account. Signs and Symptoms.—The escape of synovia from the external aper- ture, or an exposure of the interior of the articulation; are the only pathognomonic or absolute signs of a wound into a joint. Synovial fluid is recognised by its translucent, viscid, albuminous character, resembling raw white of egg ; the interior of a joint presents the additional characters of glistening synovial membrane and cartilage, and the peculiar disposition of the articular surfaces. But these appearances should be discovered by inspection, or gentle introduction of the finger ; an exploring instrument might penetrate the synovial membrane, and causeaAvound not otherwise existing. Inflammation of the synovial capsule rapidly supervenes, presenting the usual appearances of synovitis, but distinguished by two peculiarities; the intense pain, and more acute constitutional disturbance. Suppuration also is almost inevitable, Avith hectic, and irreparable destruction of the articular surfaces constituting the joint; or pyaemia intervening at an early period, proves fatal. In two cases, under my care in the Hospital, Avounds of the knee-joint exposing the articulation, both terminated in this way. Treatment.—Preservation of the limb—without any operative inter- ference—should always be attempted, in the first instance. But the pro- bability of success will depend chiefly, on the nature of the wound, and the extent of the synovial membrane or the size of the joint. A small incised wound or puncture, in a small joint, as one of the finger-joints, allows of preservation with great probability of success; a large, open, and perhaps contused wound, in a large joint, as the knee, is almost surely fatal to limb and life. Among large joints, however, those of the upper extremity—the shoulder, elbow, andAvrist, are, commonly, more favourably disposed, than in the lower extremity—the hip, knee, and ankle. To save a joint, the Avound must be at once closed, thus to solicit union by pri- mary adhesion. A pledget of lint or piece of isinglass-adhesive plaster, may be used for this purpose; or I would try the dressing Avith carbolic acid paste on tinfoil, according to Mr. Lister's plan under similar circum- stances. Repression of inflammation can sometimes be accomplished by rest and cold eAraporating lotions. Synovitis having proceeded to suppuration—the synovial capsule having become converted into an abscess, the joint should be laid freely open by incisions, as advocated by Mr. Gay ; and a position of the limb secured favourable for its utility, in the event of irreparable destruction of the articulation folloAved by anchylosis. Destruction of the joint, Avithout this issue, must be met either by excision of the diseased bone, or by amputation of the limb. The choice of these alternatives should be determined by a due consideration of the local and constitutional conditions. Fortunately, traumatic arthritis, as proceeding from the synovial membrane to the adjoining cartilages and bones, seldom engages these structures beyond the range of excision. But, the constitutional exhaustion may be so severe, as to compel recourse to secondary amputation, rather than peril life by the slow recovery conse- quent on excision. Or, amputation may become necessary—and then Avithout an alternative—after excision. 508 SPECIAL PATHOLOGY AND SURGERY. Primary amputation, it would thus appear, should not be resorted to in any case. But, in its preventive relation to pyaemia, more especially, it is questionable whether this operation might not be justifiable, occa- sionally. An open, and perhaps contused, wound, of a large joint, as the knee, represents conditions Avhich may justify immediate amputation. In my two knee-joint cases life might, probably, have been saved by such timely interArention. Fracture involving the joint, or dislocation, as complications, in similar cases, mostly demand immediate amputation. Wounds of Particular Joints are to be regarded in accordance with the general pathology and treatment of this kind of Injury. Dislocation. Dislocation.—Structural Conditions.—Dislocation is a displacement of the articulatory portion of a bone from the surface on Avhich it was naturally received; accompanied by more or less laceration of the liga- ments or other surrounding structures. Dislocations differ essentially in regard to the mode of their reparation, ac- Fig. 155. cording as they are unaccompanied, or at- tended, by an open wound communicating with the dislocation; the one being termed Simple, the other Compound. Complicated Dislocation is also a recognised distinction, signifying the concurrent injury of some other part. But this is not an essential con- dition, as pertaining to Dislocation. Con- genital Dislocation arises from malformation of the joint affected. In respect to the extent of displacement; dislocation may be incom- plete, as hinge-joint dislocations not unfre- quently are ; or complete, as those of orbicular joints usually are (Fig. 155), this difference being due to the particular shape of the articular surfaces. The primary displace- ment is made more complete, especially in orbicular-joint dislocations, by tonic contraction of the muscles, subsequently. Signs.—Dislocation is attended with a corresponding defacement or deformity of the outline of the joint; as represented by dislocation of the shoulder-joint, doAvnwards into the axilla. (Fig. 156.) The natural prominences of bone near the articulation either disappear, or are less conspicuous, as the great trochanter at the hip-joint; or they may be more prominent, as the acromion, in dislocations of the shoulder. The length of the limb is altered, and especially if the dislocation be complete. Elongation, or shortening, is produced; according as the head of the displaced bone happens to be lodged below, or above, the level of the articular surface on which it naturally moves. The possibility of either, or of only the latter, alteration of length taking place, is determined b}r the form of the articulation. An orbicular joint allows of dislocation in any direction from its circumference ; upwards, downwards, forwards, backwards. Hinge-joints cannot allow of displacement in more than three directions; backwards, forwards, and laterally, to the right or left. The direction of the dislocated bone, and thence of the limb below, is characte- ristic. Certain muscles being thrown out of action, by displacement of DISLOCATION. 509 the portion of bone to which they are attached; others thus acquiring a mechanical adArantage, preponderate. The natural balance of opposing muscles, as flexors and extensors, is lost, and the limb acquires that particular attitude to which the predominant muscles direct it. To these positive signs, may be added two negative ones; immobility of the limb Fig. 156. which gradually supervenes, in proportion to the tonic contraction of the muscles; and also the absence of crepitation. Pain, and inability to use the limb, are functional symptoms of Dislocation, but of equivocal value for an early and exact diagnosis. [P. p. 173.] Diagnosis.—The pain may be insignificant at first, before swelling supervenes ; and in oft-recurring dislocation, where the ligaments and muscles are weakened, and especially in an old feeble subject. The power of motion may be retained under similar circumstances, for the tonic contraction of the muscles is insufficient to fix the limb. But if both pain and powerlessness are present, they may each arise from other causes than dislocation ; from fracture, a bruise, or rheumatism. The physical signs of Dislocation, are, severally, more sufficient to determine the diagnosis, than in the case of Fracture. The signs alluded to are, each, in various degrees, inArariably present, and are almost exclusively connected with Dislocation. It is only as compared Avith Fracture in the neighbourhood of a joint, that Dislocation can be confounded. But, firstly, the outline of the joint is different, otherAvise than in exceptional cases. Thus, dislocations of the hip-joint may be distinguished from fracture of the neck of the thigh bone, by this sign ; so also, dislocations of the shoulder-joint, as compared with fracture of the anatomical neck of the humerus. Then again, as to altera- tion of the length of the limb; elongation is always peculiar to dislocation shortening may, hoAvever, be due to unimpacted fracture with displace- 510 SPECIAL PATHOLOGY AND SURGERY. ment. Fracture may, thus, simulate dislocation upAvards, in orbicular dislocations; or dislocation, forAvards or backwards, in hinge-joint dislo- cations. It is, therefore, only between ordinary cases of fracture and certain dislocations, that the diagnosis by this sign is equivocal. The direction or attitude of the limb is always peculiar to dislocation. Lastly, the crepitation and mobility of fracture, are both absent Avith dislocation. So far, physical signs, severally, supply an exact diagnosis. As im- mediate signs, they are of equal value for an early diagnosis ; excepting, perhaps, in regard to one physical sign—immobility of the limb. Tonic muscular contraction, AA'hereby a dislocation becomes fixed, takes place slowly; and immobility, therefore, can scarcely be regarded as an early sign of dislocation. In one case, a dislocation of the femur into the foramen ovale Avas examined by Sir A. Cooper, a few minutes after the accident; the limb was still very moveable, and continued so for the space of nearly three hours, when it became fixed. If then, the physical signs of Dislocation, are, severally more diag- nostic than those of Fracture; collectively, they cannot fail to establish the diagnosis of this injury. Causes, and effects of Dislocation.—Dislocation is produced, in general, by external force, suddenly applied. Predisposing causes are, however, very influential. Some such causes are functional actions depending on anatomical conditions; as the shape of the articular surfaces allowing a free range of motion, laxity of the ligaments retaining them, and the powerful action of many muscles on a long lever-like bone. All these predisposing conditions are combined in the shoulder-joint, and less so in the hip. Hinge-joints being more favourably circumstanced anatomically, are less liable to dislocation. Other predisposing conditions are acquired by disease; and these also have reference to the cartilage and head of bone, Avhich may be destroyed by ulceration and caries ; to the ligaments, as loosened by this process; or to those muscles which naturally aid in retaining the articular surfaces in apposition, but, Avhich may have become wasted and enfeebled, or paralysed. Dislocation itself operates as an internal cause of constitutional dis- turbance, by producing shock in a greater or less degree, folloAved by reaction ; or, this, accompanied with shock, as prostration with excite- ment ; which may be succeeded by Tetanus. [P. ch. ix.] But simple Dislocation is essentially local in its effects, and does not necessarily cause any persistent constitutional disturbance. Reparation.—The ruptured ligaments, and tendons if any be torn, are disposed to re-unite by primary adhesion ; without inflammation. Lymph is effused which speedily passes into fibrous tissue, through the medium of nucleated blastema. Any superfluous reparative material, and the blood extravasated by the injury, are absorbed ; and thus the con- comitant SAvelling subsides. The joint is ultimately restored to nearly its originally perfect construction. This presupposes the previous reduc- tion of the dislocation. If the bone remain dislodged from its natural articulatory surface or cavity, then a new joint is constructed, the mechanism of Avhich, however, is more or less complete, according to the kind of texture on which the bone has found a resting-place. If lodged on muscle, it gradually burrows for itself a convenient nest, the two surfaces become mutually adapted to each other, and, a capsular ligament being formed of condensed cellular texture, an imperfect joint is established. But if the displaced bone be lodged on bone, this loses its periosteum, and that its articular cartilage; DISLOCATION. 511 Fig. 157. a receptacle is excavated suitable to the impression of the articular surface; a bony rim or lip is throAvn up by the periosteum around the margin of this neAvly formed cavity ; the surrounding cellular texture, moreover, becomes condensed into a capsular ligament, which further provides against any displacement ; and thus a far more perfect joint is constructed. (Fig. 157.) In either case, the muscles Avhich act on the dislocated bone re- tain it in its new position, and, be- coming permanently shortened, their lines of action get accommodated to the displacement. The track through which the head of bone passed is noAv filled up with plastic lymph, and the ligaments, perhaps, have become ad- herent to the neck of the bone; the original articular cavity loses its car- tilage and closes in, undergoing also partial obliteration by a dense fibrous deposit. This articular transforma- tion is well shown in specimens— rarely procured—of unreduced disloca- tion of the hip-joint. Implying, as it does, an irretrievable sacrifice of the articular cavity, the work of destruction, in any case, proceeds very sloAvly; Nature effaces the original articulation reluctantly. The Prognosis of reduced Dislocation is favourable, with regard to re-union of the ruptured ligaments, and the tendons if any be torn ; their reparation by adhesion being subcutaneous, and not affected by exposure to the air as in the healing of an open wound. But the prognosis must be determined by a due consideration of all those internal causes, Avhich either aid the recurrence, or may prevent the original reduction of Dislocation ; and which are, moreover, persistent in their tendency to perpetuate the displacement. Causes of recurrence may be noticed first, they being among the con- ditions already mentioned as predisposing to Dislocation. Some of these conditions are, as we have seen, anatomical; a patulous shape of the articular surfaces, laxity of the ligaments, and a long lever-like bone, on Avhich many muscles act. Hence dislocations of the shoulder-joint are specially apt to recur, and less so hip-joint dislocations. Hinge-joints are, anatomically, less disposed to re-dislocation. Other such causes are morbid conditions; ulceration of the articular cartilages, and caries of the adjoining bone, relaxation of the ligaments, a weakened or paralytic condition of the muscles. Of causes opposing reduction, may be men- tioned, the anatomical shape of the articular surfaces; as the prominent rim of the acetabulum, in hip-joint dislocations, and the cup-shaped head of the radius which is locked in front of the humerus, in dislocation of that bone forwards. Any ligaments Avhich may not have yielded with dislocation, seem to bind doAvn the bone; as the first phalangeal bone of the thumb when dislocated upon its metacarpal bone. Tonic contraction of the muscles can scarcely be regarded as an unconquerable source of opposition ; but the structural change of the muscles which accompanies their permanent shortening and functional adaptation, in unreduced dis- location, is a condition of resistance, not to be overcome judiciously by 512 SPECIAL PATHOLOGY AND SURGERY. forcible reduction; and less so in proportion to the duration of this con- dition. The prognosis is that of unreduced dislocation, with the forma- tion of a neAV or substitute-joint. Treatment.—After Dislocation, especially of the orbicular joints, the muscles which favour the particular displacement, draAV the head of bone into its new position, and there fix it; but, this displacement, and subse- quent fixation, are accomplished gradually. The head of the humerus, for example, having been displaced forwards, by the violence which caused dislocation; it is then drawn imvards, and eventually, there fixed. But, i7nmediately after Dislocation, the muscles are always partially para- lysed by the shock to the nervous system consequent on the injury, and for a short period they remain powerless. Subsequently, their tonic contraction comes into operation. Therefore, at the time of dislocation, and soon after, the displacement, caused by muscular action, can be easily replaced; and any resistance, of this kind, may be partly neutra- lized by a position suitable to the further relaxation of the antagonistic muscles. This then is the earliest condition of dislocation, ere the mus- cles complete the displacement; and this the most favourable opportunity for its reduction, when the muscles are as yet powerless. Thus, imme- diately after a dislocation of the femur backwards, Liston, having this opportunity, immediately reduced it, on the spot, without pulleys, or even the help of an assistant. If Dislocation be overlooked or neglected, for a few hours, the mus- cles will have then become more immovably adapted to their new lines of action; subsequently, they become shortened also; a new joint is in process of formation ; the track through which the head of bone has passed is occupied with plastic lymph; if the rent in the ligaments be small, this aperture tightly embraces the neck of the displaced bone, which becomes adherent and more fixed ; and lastly, the natural articular surface or cavity gradually undergoes obliteration. Replacement is, at length, scarcely practicable, if possible, and certainly not to be accom- plished without endangering many structures; muscles, nerves, vessels, and perchance the bone itself; nor without re-opening the track through which the head of bone had passed, and re-rupturing the ligaments; and even then only to find the natural articular cavity effaced or obliterated. Delay, therefore, proportionately precludes replacement by any conser- vative surgical interference. The rules of treatment are precisely analogous to those relating to Fracture. (1) Coaptation or replaced position of the displaced head of bone, in relation to its natural articular surface or cavity. This implies a suitable position of the limb, as far as possible ; to relax the antagonistic muscles which, by their tonic action, retain the head of bone in a displaced position, and resist its replacement, But coaptation also implies, exten- sion and counter-extension of the limb; sufficient only to bring the head of bone parallel to its natural articular surface or cavity; the reduction of dislocation. Coaptation is then readily effected. (2) Maintenance of coaptation, during the reparative process of re- union of the torn ligaments, tendons, &c. This still pre-supposes a suit- able position; not, hoAvever, with the vieAv of relaxing such muscular contraction as maintains coaptation, but for the prevention of re-dis- placement by the spasmodic action of antagonistic muscles. But it also implies the employment of suitable retentive appliances; and both, to DISLOCATION. 513 ensure rest. This is, obviously, only the continued fulfilment, and com- pletion, of the former rule of treatment. The Reduction of Dislocation is a process; in this respect differing from the reduction of Fracture, which is readily effected. In Disloca- tion, however, reduction must be accomplished by retracing the displace- ment which has been caused by the muscles in operation; the head of bone being conducted, through the course it has thus taken, back to the point where muscular action began. Tonic contraction of the muscles will then effect coaptation. It is in retracing the course of displacement —the performance of reduction, no less than as regards the timeliness of Surgical intervention, that the guidance of pathology is chiefly expe- rienced in the treatment of Dislocation. To facilitate reduction, mus- cular resistance is eluded, partly by undertaking reduction as soon as possible after dislocation, when the muscles are as yet inoperative; and partly by placing the limb in a suitable position, as far as possible, to relax the antagonistic muscles. The semi-flexed position, as nearly as it can be attained, is the happy medium, generally desirable for this purpose. In hip-joint dislocations, flexion of the knee relaxes the three ham-string muscles; Avhile, for dislocations of the knee, the gas- trocnemius muscle also, is thus relaxed. For shoulder-joint dislocations, flexion of the elboAv relaxes the biceps muscle. And it should be re- Fig. 158. membered, that the flexor muscles are always stronger, and, therefore, more resisting than extensors. The resources for subduing muscular resistance will be noticed presently, in speaking of the act of reduction. Extension and counter-extension of the limb are necessary in all cases, and more especially for the reduction of ball-and-socket dislocations. The extending force may be either manual—as exerted by the Surgeon with an assistant or more; or mechanically applied, by pulleys. (Fig. 158.) Manual extension is less steady and less enduring; and as those who are so employed become fatigued, they relax their exertions, the muscles engaged in the dislocation regain their original supremacy and draw the bone back again to its former abnormal position; reproducing the displacement, and the work of extension has to be done all over again. Extension by means of pulleys is, however, apt to become too forcible, thereby endangering muscles, nerves, vessels, and even the bone itself; but force applied by this means can be better directed than that of per- sonal strength. In like manner, counter-extension may be maintained either by an assistant or more; or by mechanical resistance, a cloth or strap being secured to some fixed point, as a staple firmly fixed in a Avail. The relative merits of these two means of counter-extension also should l l 514 SPECIAL PATHOLOGY AND SURGERY. Fig. 159. be estimated by the respective characters of the forces, which are thus applied. As a general rule, pulleys are required only to reduce hip- joint dislocations. When employed, precautions should be taken that the integuments of the part to which the force is applied, are not injured. Extension may, therefore, be applied to the limb through a belt, padded with soft leather. If a strong woollen cloth be used instead, the noose should be fixed around the limb by the clove-hitch tie, Avhich retains its hold securely, without tighten- ing. (Fig. 159.) Besides this provision against strangulation, a damp cloth, under the noose, Avill protect the skin from friction. To what part of the limb should ex- tension be applied ? On this point, opinions are divided, as with regard to fracture. Some of the most eminent French Surgeons have recommended ex- tension to be made indirectly, from the distal extremity of the limb; from the wrist, in shoulder-joint dislocation; from the ankle, in that of the hip-joint. It is alleged that the advantage thereby gained is twofold. The muscles are not excited to spasmodic action, as they would be were force directly applied to the dislocated bone; and that besides this negative advantage, there is also the positive advantage of Fig. 160. a longer lever, whereAvith to act on the dislodged head of bone. The English School, represented by Pott and Sir A. Cooper in this branch DISLOCATION. 515 of Surgical Practice, and supported by equally distinguished Continental Surgeons, as J. L. Petit, Duverney, Malgaigne, and Callisen; have advocated extension directly, from the dislocated bone. Thus, from the arm, when the humerus is dislocated (Fig. 160); from the thigh, when the femur is dislocated. This direct application of extending force avoids endangering the intervening joints, and tells more effectually on the dis- placement. Certain it is also, that a long lever is not requisite for any truly Surgical purpose. If the muscles be relaxed, no such mechanical advantage can be necessary; if not relaxed, muscular contraction can be so directed as to eventually complete the reduction Avithout the aid of a long lever. Moreover, assuming the obvious advantage of a semi-flexed position of the proximal joint below the dislocation; this position will necessitate the application of any extending force directly to the dislocated bone. Counter-extension is most effectual Avhen applied as directly as possible, namely, from the surface corresponding to the dislocation. Supposing counter-extension to be rightly adjusted, extension should be made first in that direction which the bone has assumed by dislocation. The head of the bone is thereby made to retrace its course, and is finally replaced without any additional laceration of the textures. Then again, the extending force should be equable, not jerking, and gradually increased; accompanied, of course, by counter-extension, equal, and in the opposite direction. Any voluntary muscular resistance on the part of the patient, during reduction, is subdued by diverting his attention. A question now and then, as to how the accident happened, may answer this purpose, if no other ; and by inducing our patient to speak, we overcome any advantage which the muscles attached to the thorax, would otherwise have, were the chest fixed, as when the breath is held. This point of practice is, obviously, important in reducing dislocation of the shoulder-joint. Tonic muscular contraction is most surely overcome by the slow inhalation of chloroform; but this should not be resorted to in the first instance. Supposing increasing extension prove ineffectual, and that any further degree of such force would, or might, endanger the muscles, nerves, or vessels; then only, in my opinion, is the administration of chloroform justifiable, for then only is the occasional peril of its action warrantable as our next resource. We thus steer clear of two risks ; the former con- cerning the limb, the latter, the life. Any postponement of reduction, would not be sanctioned by pathology ; for the muscles would become more unyielding, and the head of bone, more fixed, until indeed a new and moveable articulation Avas established, and the natural one effaced; a twofold condition which would utterly forbid even the attempt at reduction. But if prior to this result, Ave fail at the time of our first attempt, and folloAved up with the relaxing aid of chloroform ; Avhat then ? I omit the objectionable measures formerly resorted to; nauseating doses of tartarized antimony, and the perhaps irrecoverable loss of the vital fluid by copious venesection, in the erect position and from a large orifice to speedily induce cerebral syncope. The warm bath may prove sufficiently relaxing; but this failing, Ave are compelled to accept the only alternative, that of Avaiting until the immediate conse- quences of extension have passed off, and then to reneAV it; aided by the repetition of chloroform, the Avarm bath, or both these relaxatives, successively. This second occasion, fairly tried, should be our last by increasing-extension ; yet it is not our last resource. Unreduceddasloca- l l 2 51G SPECIAL PATHOLOGY AND SURGERY. tions, of some duration, and not reducible by ordinary extension, prolonged even for an hour or two, have sometimes been reduced by tiring the an- tagonistic muscles ; simply by attaching a trifling weight to the limb for a few hours. This tiring-extension is quite safe, as regards both limb and life, and would, therefore, whenever practicable, be far preferable to increasing-extension under the influence of chloroform ; but, if it fails, the muscles will have gained considerable advantage by the further delay, and by the consolidation consequent on inflammatory effusion. While, therefore, tiring-extension might be a valuable safeguard, probably an assistant, in the intervals of a first and second attempt at reduction by increasing-extension, aided, if necessary, by chloroform ; as an extra re- source, it is most eligible in old dislocations, where that mode of reduction would be dangerous or useless. " The younger Cline, in this way, suc- ceeded in reducing a dislocation of the shoulder which had been out for several weeks and could not be replaced in the ordinary way. Having fixed the shoulder, a brick, attached to the hand, Avas suspended over the end of the bed. On visiting his patient next day, the bone had returned to the socket."* In the course of extension, and especially towards its completion, it is the practice of some surgeons, to rotate the dislocated bone, so as to forcibly clear aAvay any adhesions in the path along which the displaced head of bone should return home. But this forcible detrusion of any and every obstacle is prejudicial or unnecessary. It is neither conservative nor the teaching of pathology. Guided by a sufficiently exact knowledge of the relative position of the parts, as disarranged by the particular dis- location and as affected by the process of inflammation ; the Surgeon is enabled to direct the bone aright in the path it should go—to retrace its course peacefully—without thus, as it were, knocking on the head, right and left, these supposed obstacles. And if such obstacles have become established, in an old unreduced dislocation, then indeed it is very ques- tionable whether reduction should be attempted, and certainly not accom- panied with the rupturing force of rotation. Coaptation, following adequate extension, is the next, and final step, after reduction, which it may be said to complete. The displaced head of bone has been reduced, or brought back to that point Avhere the muscles first began to operate, and where it was situated immediately after the displacement as effected by the violence which dislodged the bone. It stands on the brink of its natural articular surface or cavity; the one ready to regain, the other to re-establish, the articulation. This final step, it is now the duty of the Surgeon to observe, or to undertake, by coaptation—a manipulation analogous to the setting of fracture. Surgical assistance is needed according to the resistance offered by the shape and attitude of the two articular surfaces to be brought together. Rarely, the ligaments are obstacles; solely, or additionally. The head of bone may only need guiding to its proper place, into which the muscles, if not too much relaxed, will draw it; or, it may require to be lifted over the brink of the articular cavity, if this, its margin be prominent; as that of the acetabulum, in relation to dislocation of the head of the femur. Direct manipulation is, however, more generally necessary in the coaptation of hinge-joint dislocations ; while, in ball-and-socket disloca- tions, the displaced bone is more usually guided into its hole, by properly * System of Surgery, Chelius, vol. i. p. 766, note by South. DISLOCATION. 517 directing the axis of the limb, toAvards the finish of extension. The liga- ments scarcely ever resist. They are, in most cases, extensively torn; the capsular ligaments especially so. Any ligament peculiar to the joint, is also generally torn through, as the round ligament in hip-joint disloca- tions ; but—according to the observations of Sir A. Cooper*—if one such ligament remain entire, it may occasion difficulty in the reduction, as he experienced with respect to the knee and ankle joints. In dislocations of the latter joint, it is often necessary to twist the foot, in order to relax the untorn ligament, before reduction can be effected. In dislocation of the proximal phalanx of the thumb on the posterior aspect of the meta- carpal bone, it may be necessary to divide subcutaneously, one of the lateral ligaments ; the external being most easily reached. This operation was successfully practised by Liston,j in two cases ; in an old man, much intoxicated, and a boy, after fourteen days' dislocation. In the latter case, the dislocation was reproduced accidentally, a week afterwards ; but then the reduction was readily effected—thus showing that the resistance pre- viously was unquestionably due to the undivided ligament. In all cases, coaptation should be guided by a due knowledge of the pathological con- ditions, and not effected by mechanical violence. Coaptation is announced by a snap, a jerk, or sensation of something having given Avay; this being the signal that the muscles have done their duty by drawing the head of the bone home. If, therefore, the muscular system be paralysed, as under the influence of chloroform, or if the par- ticular muscles engaged be weakened by prolonged extension, or extension be overpowering at the time of coaptation; in either case, the usual signal cannot be given. The Surgeon will Avait in vain for any such announcement of coaptation, and he cannot reasonably expect this evi- dence of its having taken place. But the limb immediately assumes its natural length and attitude, as in repose; and the natural contour of the joint is recovered. The latter sign is the one most available in practice ; for, the natural length and shape of the limb cannot be compared other- wise than by suspending extension, a cessation of effort Avhich would at once undo all that had been gained, if coaptation be not accomplished. The natural mobility of the limb is immediately regained with coaptation; and this sign, coupled with the anatomical characters just mentioned, plainly declare that the natural articulation is restored. Being thus assured of this event, the Surgeon need do but little more. Muscular contraction, having finally brought the bone into place, retains it there. Unlike fracture, the reduction of Avhich is ac- complished easily, but maintained only by watchful care; dislocation is reduced only by watchful care, after which, the muscles take care of the joint. To maintain coaptation, it is necessary only to fix the limb, and in a suitable position for the relaxation of any muscles which by their action might re-dislocate the bone. This indication is easily fulfilled by securing the limb with a bandage ; the arm to the chest, the leg to its fellow. Position and immobility are the more requisite on behalf of shallow joints, and if the ligaments are naturally loose; both of which conditions characterize the shoulder-joint. The tAVofold precaution of position and im- mobility is yet more necessary on behalf of any dislocation ; when the muscles Avhich usually prevent its recurrence, are themselves naturally * Dislocations an J Fracture of Joints. f Practical Surgery, 1846. 51X SPECIAL PATHOLOGY AND SURGERY. flabby and weak, or have been Aveakened by the dislocation, and by the extension necessary for its reduction. If, in such case, the limb be not securely fixed and supported in a suitable position; it may re-dislocate itself, not so much by the action of antagonistic muscles, as by the mere weight of the limb. Rest of the limb, thus retained in position, will also favour the sub- sidence of any inflammation Avhich may have supervened. But, the in- flammation being subcutaneous, it terminates in resolution, very rarely in suppuration. Any so-called antiphlogistic treatment, therefore, is as seldom necessary; certainly not of a constitutional character, and locally only, by the application of a cold lotion in the first instance; Avith subsequently friction daily to revive the dormant muscles. Ample time must be allowed for firm re-union of the ligaments or other lacerated textures; failing which, the joint Avill be permanently weakened and ever liable to re-dislocation. On the other hand, judicious exercise of the joint, by passive motion occasionally, will prevent the tendency, otherwise, to some degree of anchylosis and permanent stiffness; with the irrecover- able loss of muscular power in the limb. Compound Dislocation. — Structural condition, and Diagnostic charac- ters.—Compound Dislocation is, essentially, Dislocation, with a wound in the skin communicating; thus exposing the injured joint, however in- directly, to the action of the air. The structural disorganization as re- gards the state of the joint, is the same as in simple dislocation ; but compound dislocation is usually accompanied with more severe contusion or laceration of the surrounding soft textures. This condition, coupled with that of the aperture externally—which is also contused or lacerated; together form a Contused or Lacerated Wound, connected with, and around, a Dislocation. The Signs of this injury are the same as those of simple dislocation, with the additional and distinctive character of an external irregular Avound. In short, both the condition and characters are those of simple Dislocation, plus those of contused or lacerated Wound. Compound dislocation occurs most frequently in the ankle-joint; oc- casionally in the knee and elbow; rarely, in the shoulder; and very rarely, in the hip-joint. Causes, and Effects of Compound Dislocation.—Here also, the patho- logical history is that of simple dislocation, Avith certain peculiarities superadded. Generally speaking, the dislocated bone, having passed through the adjoining soft parts, in the direction of the displacement, and come to the surface, it protrudes through the skin ; and thus the wound is an extension of the injury from within. But, in some cases, external violence is the cause of the wound in the skin and subjacent soft parts, as Avell as of the connected dislocation: which may then be regarded as produced by an extension of the injury from without. In the one case, the force is applied indirectly, to the bone at some distance off, and the injury is more a laceration, and less extensive; in the other case, the force is applied directly to the joint, and the injury is more a contusion. In both cases, the lacerated or contused textures are damaged beyond the apparent extent of injury ; and the shock to the nervous system is more severe than with simple dislocation, OAving to the greater damage to the soft parts, including nerves. Tetanus is, perhaps, more likely to occur than after a contused or lacerated wound alone, and especially if the compound dislocation COMPOUND DISLOCATION. 519 be that of a ginglymoid joint, as of the thumb. Injuries of unyielding fibrous or ligamentous textures are, generally, prone to induce Tetanus. [P. p. 442.] J * The textures injured, being in a state of disintegration, die, at least to some extent around, if the wound be allowed to remain open. This purely traumatic gangrene is the same as that caused by a lacerated or contused wound. Limited, therefore, to the part injured," and defined, eventually, by a line of demarcation between the living and dead tex- tures; the gangrene is also immediate, if the injury itself be severe. Course and Terminations.—Inflammation supervenes, followed by suppuration, often profuse, and partial sloughing ; or gangrene, possibly, on a larger scale. Yet this also is limited to the seat of injury. Ulti- mately, compound dislocation, when reduced, not unfrequently undergoes reparation; the torn ligaments and tendons becoming reconnected, and the wound closing up by the healing process of suppurative granulation and cicatrization. Spreading gangrene—due to some morbid condition of the blood—is only contingent, occasionally, on compound dislocation; just as it may be associated with compound fracture, and with contused and lacerated wounds. The phenomena of this species of gangrene were described under the last-named form of Injury. The Prognosis of Compound Dislocation, as gathered from the fore- going elements of its natural course and tendency, is far less favourable than that of simple Dislocation. An open Avound, communicating with the joint, as compared Avith subcutaneous laceration of the soft parts, is one unfavourable ground of prognostic distinction. Scarcely less so, is the greater extent of their laceration, usually, in compound Dislocation, especially if produced by direct violence. [P. p. 724.] Spreading gangrene is an adventitious condition, but as implying the co-opera- tion of a constitutional cause, it has a most unfavourable significance. [P. p. 737.] Treatment.—The same rules of treatment are applicable as for simple dislocation; but, certain particulars, having reference to the special pathology of compound dislocation, are peculiar to its treatment. Reduction of the displacement may present special difficulties. Thus, if the bone protrude—Excision is preferable to Ariolent efforts at reduc- tion. The head of the astragalus has been removed, Avhen, by dislocation forwards, it protruded and could not be returned. 'The Wound.—Reduction having been accomplished, and the limb retained in a suitable position—to prevent the recurrence of dislocation— by appropriate bandaging or apparatus; the treatment peculiar to compound dislocation is that relating to the wound, and state of the soft parts in- volved. The primary indication is to close the wound, with the view of soliciting its union by adhesion, and thus convert the dislocation into a simple one. For this purpose, a pad of lint—soaked in blood from the wound, as formerly practised, or better, simply wet lint, or soaked in carbolic acid solution, should be applied over and around the wound—so as entirely to exclude the air. But—subsequently—watching the pro- gress of the case ; Avhen primary adhesion becomes obviously impossible, the attempt should be forthwith discontinued, in order to give free vent to matter, during the process of suppuration. Early solicitation of heal- ing by primary adhesion, and timely abandonment of the attempt, in favour of suppuration, as soon as this event occurs, or is inevitable; 520 SPECIAL PATHOLOGY AND SURGERY. constitutes a compromise, which overrules any objection as to the probable failure of the one, and the supervention of the other. It may secure the advantage, otherwise forfeited, of then having to deal with only a simple Dislocation. In the event of Suppuration ; early, free, and dependent incisions are indicated, for the same reasons, as in compound fracture ; and a poultice, or spongio-piline soaked in Avarm Avater as a fomentation, is now the ap- propriate application ; to be exchanged for light water-dressing, or Avith carbolic acid solution, Avhen the continuance of Avarmth Avith moisture would only sodden and relax, and when the wound is granulating. The same hygienic and medical treatment also, as for compound fracture, will prove efficacious in sustaining the system under the hectic fever and ex- haustion consequent on prolonged and perchance profuse suppurative dis- charge, and in overcoming the typhoidal fever induced by gangrene or sloughing. Amputation.—The " question of amputation," depending upon the supervention of either profuse suppuration or gangrene; the propriety of this operation is determined by pathologico-anatomical conditions parallel to those of compound fracture. (1) Primary amputation, only when the Fig. 161. whole substance of a limb being involved by compound dislocation, the limb itself is already, in the first instance, virtually lost, and life a's in- evitably endangered. Such was the condition of compound dislocation, represented in (Fig. 161), the integuments having been removed from the limb to display the various kinds and extent of lesion. Unique, as a new form of elboAv-joint dislocation, by dislodgment of the radius and ulna outwards and upwards on to the external ridge of the humerus above the condyle, the forearm had thus undergone an " external latero-angular dislocation." The relative position of the bones, and thence the peculiar appearance of the joint externally and configuration of the limb, are more particularly described in the Brit, and For. Med. Chir. Rev., January, 1866. As justifying amputation—the lesions co- existing were these. A large lacerated wound about the middle of the forearm in front, exposing the muscles and a portion of both bones, with the interosseous membrane. All the flexor muscles, superficial and COMPLICATED DISLOCATION. 521 deep, Avere torn across, partially or entirely, sparing their tendinous and aponeurotic portions, which appeared deep in the wound as so many shreddy strings from which the muscular substance had been raked off. All the vessels and nerves, however, excepting, of course, their muscular branches, had escaped rupture; the ulnar nerve, the inferior profunda artery accompanying it above the joint, and the ulnar artery in the forearm, the median nerve with its interosseous branch and the corresponding branch of artery, and lastly, the radial artery and nerve. But the skin was almost completely detached from the sheath of the muscles on the front and back of the forearm, and some way above the joint. The large tract of subcutaneous cellular texture thus disorganized was infiltrated with blood, not discernible through the skin, Avhich ap- peared unbruised. A small contused aperture just above and behind the inner condyle communicated directly with the joint, constituting a com- pound dislocation. This extensive injury was caused by severe con- tusion and a lacerating wrench between the buffers of two railway carriages. (2) Secondary amputation, when the extent of damage done by the injury being itself partial, the supervention of profuse suppura- tion or gangrene is only proportionately probable ; and the limb, there- fore, not inevitably lost, nor the life perilled. Such postponement of amputation is justifiable to give the limb its chance of preservation by delay; while the preservation of life is provided for by timely amputation, when the adverse circumstances, alluded to, actually supervene. The rules laid doAvn in surgical Avorks, Avith reference to the extent of injury, are not the expressions of a sufficiently accumulated pathological experience, in different doubtful cases; and they over- look the necessarily unknown capabilities of reparation in different individuals. Cases occurring, from time to time, which have proved exceptional to any such rules, suggest the all-important consideration; in how many more cases might limbs be saved which are thus sacrificed surgically ? No extent of injury, as to the vessels, nerves, muscles, and integu- ments—short of the Avhole substance of a limb being involved—in con- nexion Avith compound dislocation, can be said to absolutely prohibit the attempt to preserve the limb, in the first instance. Thus, compound dislocation of the knee-joint, Avas pronounced by Sir A. Cooper to be a condition of disorganization Avhich imperatively de- manded primary amputation. Exceptions, occasionally, have since dis- proved that dictum, in this form of injury. In the case of a boy, nine years of age, at the Westminster Hospital, Mr. White succeeded in saving the limb, by sawing off the condyles of the femur and reducing the bone. In the ankle-joint the end of the tibia may be removed and reduction accomplished ; a proceeding which I remember Mr. Liston advocated nearly a quarter of a century ago. A person jumps out of a carriage behind, Avhile the horse is running away, and alighting on his feet, the tibia of either leg may be driven through the integuments and, perhaps, come in contact Avith the earth. Removal of the bruised portion of bone, will facilitate the reduction, and has proved successful in preserving the limb. Dislocation of the astragalus, in like manner, may be similarly treated. Excision, indeed, bids fair to surpass amputation in other com- pound Dislocations. Complicated Dislocation.—Dislocation may be complicated by asso- ciation Avith the laceration of muscles which are put upon the stretch ; as 522 SPECIAL PATHOLOGY AND SURGERY. the pectineus and adductor brevis, by dislocation of the thigh doAvnwards into the thyroid foramen; even their unyielding tendons are sometimes ruptured, as the sub-scapularis tendon, by dislocation into the axilla. Large blood-vessels occasionally share the same fate, accompanied with haemorrhage and livid swelling; a main nerve also may be torn asunder. Fracture of the shaft or of the head, of the bone dislocated, is another complication. This is more likely to occur in dislocation from direct violence ; as by a fall on the hip or shoulder, the neck of either bone is perilled ; the olecranon also may be knocked off; the bulky head of the tibia shattered; or the tarsal end of the tibia broken and bruised. Thus, then, all the parts around a dislocation are liable to be involved in the injury. But, obviously, none of those special injuries to internal organs can occur, Avhich may complicate the Fracture of certain bones. Respecting morbid conditions ; local diseases—i.e., of the joints themselves, may pre- dispose to dislocation and thence to its recurrence, by previous disorgani- zation of the joint affected; a parallel kind of complication to that of fracture from disease of the bone. So also, the diseased condition of the joint is frequently a local manifestation of some blood-disease—e.g., syphilis or scrofula, as a constitutional cause, rather than of traumatic or local origin. Whenever dislocation from disease of the joint has the former mode of origin, the reparative process is proportionately slow and uncertain; the more so when the contitutional disease is actually in operation. Of all these complications of Dislocation ; those which are combina- tions of other forms of injury thereAvith, have been already noticed in con- nexion with compound Dislocation; while predisposing diseases of the joints, will be taken in relation to Unreduced Dislocation. Treatment.—Both the general considerations of pathology, and the corresponding Rules of Treatment, pertaining to Complicated Fracture, are applicable also to Complicated Dislocation. lstly. If any morbid condition be in operation, locally or constitu- tionally, the treatment must be entirely subject to such causative condi- tion, as connected Avith the Dislocation. 2ndly. If there be any injury additional to Dislocation ; the treatment of the dislocation may be of entirely subordinate importance, even although it be, as in many such cases, severely compound. Unreduced Dislocation and False-joint ; Congenital Dislocation.— These pathological conditions may be taken consecutively ; the one as the result of neglected or possibly, irreducible Dislocation, the other, as being irreducible or incapable of continued reduction, owing to some con- genital malformation. Both are supplementary to the pathology and treatment of ordinary Dislocation. Unreduced Dislocation, and False-joint.— Structural Condition.— The alterations of structure consequent on unreduced Dislocation are, the formation of a new joint, the obliteration of the former or natural articu- lation, and of the track through which the head of the dislocated bone passed to its present locality. The new joint is more, or less, perfectly constructed. If the displaced bone be lodged upon muscle; it gradually burroAvs for itself a convenient nest, the two surfaces become mutually adapted to each other, and a cap- sular ligament being formed of condensed cellular tissue, an imperfect joint is established. But should the bone have found a resting-place on bone, this, by absorption, loses its periosteum, and that, its articular cartilage; a receptacle is excavated suitable to the impression of the dis- UNREDUCED DISLOCATION AND FALSE-JOINT. 523 placed articular surface ; a bony rim or lip is thrown up by the periosteum around the margin of this neAvly formed cavity, the surrounding cellular texture, moreover, becomes condensed into a capsular ligament, Avhich further provides against any displacement; and thus a far more perfect joint is constructed. (Fig. 162.) Fig. 162. A porcellanous deposit takes the place of cartilage, on the head or surface of the dislocated bone; or instead of this ueburnation," an im- perfect fibro-serous surface or synovial capsule may be formed. (Hamilton.) The natural articular cavity—Avhence the bone Avas dislodged—loses its cartilaginous investment, and closes in. It is, at length, partially oblite- rated by a dense fibrous deposit. (See Fig.) So also is the track in the textures, through which the bone had passed. Associated Avith this articular transformation, are certain accessory, but somewhat accidental changes, in relation to the ligaments, muscles, and tendons. The ligaments perhaps become firmly adherent to the neck of the bone, thus further opposing its reduction, and if the rent be small through Avhich the bone escaped, it may be tightly embraced. This is more apt to occur in a capsular ligament. Other ligamentous conditions are peculiar. The orbicular ligament around the neck of the radius may have been carried away entirely by dislocation of this bone, and be firmly attached at both ends to the humerus. A specimen of this kind is preserved in the museum of St. George's Hospital. The muscles which act on the dis- placed bone become permanently shortened, Avhile their lines of action get accommodated to the displacement, and help to retain the bone in its new position. Or if any tendons Avere partially or entirely torn across by the violeuce of dislocation, they may have acquired new attachments, and such as are mechanically unadapted to the action of the muscles. A rup- tured tendon sometimes forms a band of adhesion betAveen the bones. In one instance,* the tendon of the brachialis anticus muscle, having been torn off the coronoid process of the ulna, which Avas dislocated backwards into the olecranon fossa; this tendon become firmly united both to the * Specimen of dislocated elbow. Museum of St. George's Hospital. T. Holmes. 524 SPECIAL PATHOLOGY AND SURGERY. trochlear surface of the humerus and to the ulna below its original attachment, forming a kind of soft anchylosis between them. A tendon thus attached, is unfavourable to the action of the muscle connected there- with, yet its attachment aids in rendering the dislocation irreducible. Bony nodules form, occasionally, in the tendons around the seat of dislo- cation. Lastly, in these general changes, should be noticed the important one of adhesion sometimes having taken place between a large artery and the capsule or periosteum of the displaced bone.* All these structural alterations take place very slowly. The destruc- tive changes, implying an irreparable sacrifice of the articular cavity, Nature reluctantly obliterates it, and with it the opportunity for reduction ; only when long disappointed by delay and wearied by the lapse of time. The reparative alterations—those pertaining to the formation of a new joint—are most complete in ball-and-socket dislocations, as the hip-joint ; the compensatory substitute for any hinge-joint is far less complete. In some such instances even, bony anchylosis is the result. The Diagnostic Signs of unreduced Dislocation, and of the construction of a new joint, are; the physical signs of dislocation, coupled with resto- ration, more or less entirely, of the functional use of the limb or part. The characteristic alterations, in the form of the joint, length of the limb, and direction of its axis, still remain ; while the power of using it is regained, and proportionately as the new articulation is perfectly finished off. Hence, this restoration of function is, at length, far more thoroughly established in unreduced Dislocation of a ball-and- socket joint, than in that of a hinge-joint. Treatment.—The question of interference should be determined by the mobility of the neAV joint. (a) When freely moveable, the natural articular cavity or surface is probably obliterated ; the processes of con- struction and destruction having proceeded simultaneously and correla- tively. Hence, the indication is, not to interfere, to leave such an unreduced dislocation alone ; any attempt at reduction being useless or worse. Under these circumstances, reduction has, indeed, been effected, but with great injury to the limb, and even with a fatal result. In one such case, that of a dislocated shoulder, reduction was followed by great SAvelling of the arm, a tumour formed in the axilla, which, at the end of thirty-eight days, burst with alarming haemorrhage. Ligature of the subclavian artery fortunately saved the patient's life.j In other cases, suppuration in and around the joint, and gangrene of the limb, have been known to occur.| (b) When the action of a new joint is less easy, and less efficient; reduction of the dislocation may be attempted, and with successful issue to limb and life. The kind and amount of extension, are, however, features in the treat- ment, worthy of special attention. Extension, gradually increased, and continued for perhaps some hours, or renewed daily, is necessary; to overcome the resistance of the shortened muscles, any adhesions of the tendons or ligaments, and to extricate the bone from its new articular adaptations. But, it should ever be remembered that, possibly, more than these mechanical obstacles to reduction, exist. There is always some risk of rupturing any blood-vessels which may have become ad- herent. Yet this is an accident which cannot be foreseen, otherwise than * Op. cit., Hamilton, 1860, p. 492. + Med.-Chir. Trans., 1846, vol. xxix. p. 25. X Traite" des Fractures, etc., Malgaigne, vol. ii. p. 143. UNREDUCED DISLOCATION AND FALSE-JOINT. 525 by observing the general rule laid doAvn respecting any surgical inter- ference. Of course, reduction should be conducted under the influence of chloroform. The extreme periods of unreduced Dislocation, within which limits reduction is practicable, with safety to the limb and life of the patient; can scarcely be determined by experience. Nor is this question of much practical importance, considering the functional conditions, already mentioned, which should guide the Surgeon. Successful results have been obtained at extreme periods, varying from a feAv days to many months, and even beyond two years! In a dislocation of the elbow, backwards, unreduced for six months, Mr. Darke* continued extension with pulleys during eight hours and a half, when the bones returned to their proper situation. Three other cases of this date were successful in the hands of Gorre and Gerdy.j A dislocation of the shoulder, unreduced for six weeks, was overcome by Mr. Mash,J in the Northampton Infirmary, by extension at intervals with pulleys, during eight hours. A dislocation of the head of the radius forwards, of twenty-five months, in a child nine years old, was reduced by Dr. Stark ;§ extension being repeated daily for twenty-tAVO days, consecutively. This is, I believe, the longest period at Avhich such extension has been successful, in unreduced dislocation of any joint in the upper extremity. Manual extension has proved sufficient in some cases. Thus, I reduced a dislocation of the radius backwards, of ten weeks; the adhesions about the head of the bone audibly giving way. In the lower extremity, the periods of limitation have been much less, with regard to the hip-joint. In two instances, dislocation of the femur on the dorsum ilii, has been reduced after the lapse of six months. In both, reduction Avas effected by " manipulation ;" the one,|| under the influence of chloroform, the other,^[ without; but in this case the patient, a boy, was feeble and the muscles flaccid. In both, the results were successful; the limb re- covering its functions and the muscles regaining their bulk and strength. Respecting the hip- and shoulder-joints; Sir A. Cooper's large ex- perience led him to select two months in the one case, and three months in the other, as the extreme periods at which reduction can be safely accomplished. Any opposing tendons, ligaments, or adhesions, suggest the propriety of a previous accessory operation ; that of dividing them, subcutaneously. Simple as this may appear, it is not always practicable, with a fair degree of safety to the part, and even to the life of the patient. Yet there are successful results on record. Thus, in dislocation of the thumb back- Avards upon the metacarpal bone, reduction may be impossible, unless by subcutaneous division of the lateral ligaments. Sir Charles Bell first proposed the operation in this case, and it has since been successfully practised by Liston, Reinhardt, Gibson of Philadelphia, Parker of New York, and other Surgeons. Lizars and Syme advocate this practice in certain instances. An unreduced dislocation of the shoulder-joint, of two years' duration, was overcome by Dieffenbach, in like manner. In one instance also, an old dislocation of the elbow, Avhich still resisted after * Prov. Med. Journ., Dec, 1842, p. 250. t Me"m. sur les luxations du coude. P. Denuce, 1854, p. 86. X Lancet, Sept., 1844. § Edin. Med. and Surg. Journ., 1848, vol. ix. p. 77. || By Dr. BlackmaD, Ohio Med. and Surg. Journ., vol. viii. p. 522. 11 Fractures and Dislocations, Hamilton, 1840, p. 663, Philadelphia. 520 SPECIAL PATHOLOGY AND SURGERY. division of the tendons and ligaments, av.ts reduced by dividing the adhesions. M. Blumhardt* made a longitudinal incision on either side of the joint, laid open the capsule, freely divided the adhesions, and replaced the bones. The limb is said to have recovered its natural mobility, and the patient resumed his occupation as a carpenter. In cases such as these, the periods after dislocation, at which ope- rations have proved successful, are comparatively unimportant; for the difficulties of reduction being thus overcome, the operation itself is the only important consideration—i.e., as to its propriety and practica- bility. Congenital Dislocations.—The Avhole pathology of " Dislocations existing at birth," requires further investigation, in respect to their structural conditions, causes, and vital history. Congenital Dislocations are, apparently, of three kinds: (a) Physio- logical dislocations; or those resulting from an original defect in the germ, or from an arrest of development, (b) Pathological dislocations ; or those resulting from some lesion of the nervous centres, from contrac- tion or paralysis of the muscles, laxity of the ligaments, hydrarthrosis, or some other diseased condition of the articulation, (c) Mechanical disloca- tions ; or those resulting from some peculiar position of the foetus in utero, violent contractions or constant pressure of the walls of the uterus, falls and blows upon the abdomen, and unskilful manipulation of the child in delivery. These might be termed traumatic dislocations. Pro- bably all the joints are liable to congenital Dislocation, in some form or forms ; and Avith regard to most of the joints, this kind of lesion has already been established by dissection. Hamilton has collected many such instances; but it appears to occur most frequently in the hip and shoulder-joints. The Treatment of Congenital Dislocation is generally impracticable. What to do may be ob\-ious; the removal of any one, or more, of the known conditions which originally produced the dislocation; but hoAv to do this successfully, may be impracticable, owing to those condi- tions being, generally, defective forms of structure, which, in pro- ducing, also perpetuate the recurrence of dislocation. Persistency of the cause, or causes, in operation, thus renders these lesions mostly incurable. The fact of congenital dislocation of the hip occurring, was known to Hippocrates, and expressly noticed in his Avork, " De .Articulis." Other early authors, Avicenna, Pare, and Kerkring, also mention such disloca- tion of this joint; the latter recording an example verified by dissection. Subsequently, Chaussierj recorded a congenital dislocation of the shoulder, and another of the hip, both in the same infant. Paletta, of Milan, added to the cases then known ;| and, in his hands, the injury first assumed a pathological character.§ But it was reserved for Dupuytren|| to investigate congenital dislocations, enlightened by pathology and physiology. Among other special authorities, the following have con- tributed the most valuable sources of information :—Breschet,^" Caillard- Billioniere,** Lehoux,yy Sandiforte,t.t. Duval and Lafond, Humbert and * Gaz. He'd., 1847, p. 238. t Bulletin dela Fac. et de la Soc. de MeU, 1811-12. X Adversaria Chir., 1788. § Exercitationes Path., 1820. || Lecons Orales. Trans, by Syd. Soc. U Repertoire d'Anat. et de Pbysiologie. ** These Inaugurate, 1828. ft These Inaugurale, 1834. XX Thesis—before Fac. of Med., Leyden. DISLOCATIONS OF THE LOWER JAW. 527 Jacquier, Bouvier,* Sedillot,f Gerdy, Poliniere, Vrolik,J Guerin,§ Parise,|| Pravaz,f Carnochan,** R. Smith,tt and last, not least, Malgaigne.JJ CHAPTER XXXIII. special dislocations. Dislocations of the Loaver Jaw.—Structural conditions.—Complete dislocation on both sides consists in the dislodgment of both condyles from the glenoid fossae, and their displacement forwards, in front of the anterior or transverse root of the zygoma, on either side; the coronoid processes thus being brought forward, and corresponding Fig. 163. to the under aspect of the malar bone, on either side. (Fig. 163.) Similar dislo- cation on one side only, re- presents the same altered articular relations of the condyle, on that side; with a twist of the jaw to the op- posite side. Partial dislo- cation, or subluxation of the jaw, is, apparently, a displacement in relation to the inter-articular carti- lages ; the condyles slipping forwards in front of these cartilages, on both sides, or on either side alone. Bilateral dislocation occurs in about tAvo of every three cases. Partial dislocation happens, comparatively, seldom. Signs.—Certain obvious and characteristic signs attend dislocation of the jaw. The mouth is open, the jaw being drawn doAvn by the action of the genio-hyoid muscles, and the lower teeth project in front of the line of the upper teeth. This open-mouthed appearance is more con- spicuous at first, the distance between the teeth extending sometimes to an inch and a half; subsequently the jaws become more closed, but the coronoid processes, hitching against the malar bones, mechanically oppose any nearer approximation. Deglutition and speech are interrupted, the lips moving when the person attempts to speak and the saliva dribbling * Duval and Lafond, Humbert and Jacquier, Bouvier.—See Pravaz. t Journ. de Connais. Med.-Chir., 1838. X Gerdy, PolinieVe, Vrolik.—See Pravaz. § Recher. sur les Lux. Congen. 1841. || Archiv. Gen. de MeU, 1842. ■ Traite" The"orique et Pratique des Lux. Congen. du Fe'mur; suivi d'un Append. sur la Prophylaxie des Lux. Spontane"es, 1847. Lyon. ** Etiology, Pathology, and Treatment of Cong. Dis. of Head of Femur, 1850. New York. ft Fractures in Vicinity of Joints, and on certain Accidental and Cong. Disloca- tions, 1854. Dublin. ii Traite des Fractures et des Luxations. 1855. 528 SPECIAL PATHOLOGY AND SURGERY. over the chin. The cheeks are stretched and flattened, and the angles of the jaw directed somewhat backAvard towards the mastoid process of the temporal bone, on either side; a depression can be felt in front of the external auditory meatus, corresponding to the natural situation of the condyle, and an oblong promi- nence in the temporal fossa with fulness of the masseter muscle. (Fig. 164.) Dislocation on one side only is denoted by the same signs; but in a lesser degree, and one-sided, the jaAV being tAvisted somewhat to the opposite side, though this alteration may be scarcely appreciable. A depression can always be felt in the proper situation of the condyle, and not on the other side. Partial dislocation presents similar signs, but they are still less perceptible, and perhaps recurring, the condyle slipping to and fro. Causes. — Muscular action would seem to be the usual cause, in the act of opening the mouth widely; as in laughing, gaping, '/ / 'J violent declamation, yaAvning, or an attempt to take too large a bite. The condyles moving forward on the transverse root of the zygoma on either side, are dislocated by the action of the external pterygoid muscles ; the genio-hyoid muscles then depressing the jaw. External violence is an occa- sional cause, as in tooth-extraction, or the forcible introduction of some- thing into the mouth. Sir A. Cooper records such a case; tAvo boys were struggling for an apple, and the one in attempting to thrust it into his own mouth, dislocated his jaw. Age would certainly seem to have some predisposing influence; complete dislocation occurring very rarely in infancy or advanced life, owing probably to peculiarities in the form of the jaw at these periods. Nelaton attributes its greater frequency in middle life, to the length and anterior inclination of the coronoid process. Women also seem more liable than men ; and to partial dislocation in particular, which arises probably from relaxation of the ligaments of the jaw. Unreduced dislocation of the jaw undergoes changes, whereby the jaw becomes approximated to the upper and its anterior projection is diminished, some mobility and poAver of movement also are regained; thus restoring mastication, deglutition and speech so far, that the person at length experiences no great inconvenience from the displacement. Treatment.—Reduction is readily accomplished by retracing the dis- placement. The Surgeon standing in front of his patient, introduces his thumbs—protected by a cloth—into the mouth, and applies them to the lower molar teeth on either side; depressing the angles of the jaAV, the chin is raised by the fingers externally at the same time, and the jaw is jerked in or returns with a snap. Dislocation on one side is reduced in like manner; and so also partial dislocation, which may, however, be DISLOCATIONS OF THE CLAVICLE. 529 returned by the natural efforts to open and shut the mouth, the patient being told at the same time—as suggested by Professor Pirrie—to bring the jaw forward. A four-tailed bandage must then be applied, as in frac- ture of the loAver jaw ; and the patient fed on liquid food for some days, during reparation of the ligaments. After partial dislocation, the pre- vention of its recurrence may be aided by tonic treatment, and stimulant applications over the articulation. Reduction has been effected after periods varying from days to several Aveeks; after one month and five days, by Sir A. Cooper, in a case of double dislocation; and after ninety-eight days, Donovan succeeded, in another case. Congenital Dislocation of the Lower Jaw—denied by Malgaigne, but affirmed by Guerin, R. W. Smith, and Hamilton; is, hoAvever, very rare. In Dr. Smith's complete account of one such case; dissection shoAved an arrest of development of the dislocated side of the face; the osseous and muscular structures being atrophied and imperfect. A singular defor- mity of the face was thus occasioned, on the one side as compared with the other; and the usual signs of dislocation Avere absent or reversed,— the front teeth of the upper jaw projected beyond those of the lower, the mouth was closed or opened voluntarily, and these movements of the jaAV were more extensive than in the normal condition. This congenital dislocation is incurable. Dislocations of the Spine are almost necessarily accompanied with fracture of the articular processes, and of the bodies of the vertebrae; excepting in the cervical region, the articular processes there being placed more obliquely than those of the other vertebrae. Any dislocation of the spine is rare, and more so without fracture. Separation of the inter- vertebral substance, and displacement of the bodies of the vertebrae, may also occur. I have seen one such case, as shown by post-mortem exa- mination. The Signs and Symptoms of spinal dislocation are similar to those of fracture in this region; some irregularity or projection at the seat of dislocation, and paralysis, more or less complete, of those portions of the body Avhich receive the nervous supply from below the point at Avhich the dislocation has occurred. The diagnosis, as compared with fracture, can hardly be determined by crepitus, which may be absent in fracture, and present in all the dislocations accompanied with fracture; but, a peculiar rigidity of the spine in the position assumed by dislocation—the trunk inclining immovably forAvards, backAvards, or more commonly to one side, -will generally be diagnostic. Causes.—The same as in fracture ; falls on the head, feet, or back, and violent flexions of the spine backwards, or to either side. Termination.—Dislocations of the spine are, obviously, of a serious or fatal character; and—like fracture—more so, the higher in the spinal column dislocation occurs. Treatment.—Reduction of the displacement is impossible, or would be perilous; and but little can be done beyond the general treatment for fracture of the spine. Dislocations of the Clavicle.—(1) The sternal end of the Clavicle may be dislocated; forwards, in front of the sternum; backwards, behind the sternum ; and upwards, or upwards and inwards, above the sternum. In these dislocations, the ligaments are more or less completely torn, ac- -AI M 530 SPECIAL PATHOLOGY AND SURGERY. cording to the direction and extent of the displacement; but the bone carries with it the clavicular portion of the sterno-mastoid muscle. Signs.—Dislocation forwards is denoted by a deformity, consisting of the sternal end of the clavicle in front of the sternum (Fig. 1G5), which disappears by drawing the shoulders backAvards and returns when such force is removed; the distance between the acromion and middle line is diminished; the head is draAvn forAvards and turned from the dislocation, in order to relax the sterno-mastoid muscle; and there is in- ability to raise the upper extremity. Dislocation backwards is denoted by _ ---^->~~ <^.-ti-F^-V^ *ne °PPoshe appearance to the former yB|^_^^**«s^_ --^L. i «-. vessels and nerves, respectively. Seve- ^__--f{ ^— ral cases are recorded in the " London \ -, ^^^ni — —fr f- and Edinburgh Journal of Medical 1 > j Science," October, 1841. Dislocation I ^ ( upwards is of rare occurrence; four V- '],_ j cases only having been collected by X^y Malgaigne, and a fifth, an extraordi- nary case, by Hamilton, as described by Dr. Rochester in the " Buffalo Medical Journal." This form of dislo- cation presents a projection above the sternum—or in the remarkable case alluded to, upon the front of the thyroid cartilage—the sternal end of the clavicle having been thrown upwards; and there is also a corre- sponding depression of the shoulder. Causes.—A fall on the shoulder, anteriorly, or throwing the shoulder backwards, may cause the dislocation forwards; compression of the shoulders, laterally, or a direct blow on the sternal end of the clavicle, may drive this portion of the bone backwards; and a fall on the shoulder externally, or a blow upon the top of the shoulder, may start the bone upAvards, upon the supra-sternal notch. In one case, this dislocation was occasioned by direct violence, a bolt thrust up from under the clavicle. Treatment.—Reduction of these three dislocations is accomplished by directing the shoulder so as to retrace the particular displacement. For- ward dislocation of the sternal end of the clavicle may thus be overcome, by drawing the shoulder backwards and outwards; in backward disloca- tion, similar traction of the shoulder, to even a greater extent, will be efficient; while upward dislocation may be reduced by outward traction of the shoulder, at the same time raising the outer and depressing the inner end of the clavicle. Pressure directly on the displaced end of bone, when accessible, as in the first and last named dislocations, has comparatively little effect in aiding reduction. Traction of the shoulder is best effected by using the knee as a fulcrum in the back, Avhile an assistant places his fist as a fulcrum in the axilla; the shoulders are then bent backwards, and the elbow brought down to the side, simultaneously. To retain the bone in position; a pad over the sternal end may have some effect in dislocation forwards; but a figure-of-8 bandage applied to the shoulders Avill more effectually prevent the recurrence of displace- DISLOCATIONS OF THE CLAYICLE. 531 ment in either of the three directions of dislocation, the arm being draAvn back and fixed to the side. Some permanent displacement and deformity are almost inevitable; the patient, hoAvever, recovering a good use of the arm. Compound dislocation occurred in one instance of dislocation back- Avards, by direct violence. (Hamilton.) (2) The scapular ends of the Clavicle may be dislocated; upwards, upon the upper surface of the acromion (Fig. 166); or downwards, under the acromion, or under the coracoid process. The first- named dislocation is the most frequent, and indeed the most common of all dis- locations of the clavicle; the second very rare, only 3 cases having been re- corded of dislocation under the acro- mion, and 6, under the coracoid process. The acromio-clavicular ligaments are torn in the dislocation upwards: and, also, the coraco-clavicular and coraco- acromial ligaments in dislocation down- wards. Signs. — Dislocation upwards is easily recognised by the projection of the outer or scapular end of the cla- vicle, and which is more easily felt on tracing the spine of the scapula up to the acromio-clavicular articu- lation. Some depression and flatness of the shoulder Avill also be per- ceptible. Dislocation dowmcards is recognised, and distinguished, by the opposite signs; a marked depression, in particular, corresponding to the usual situation of the outer end of the clavicle. DoAvnward disloca- tion, under the coracoid process, is more particularly characterized by a corresponding projection of the acromion and coracoid process, and a rapid inclination doAvmvards and outwards of the line of the clavicle, its outer end being felt in the axilla. Inability to raise the arm to a right angle Avith the body, Avill generally be found symptomatic of either form of dislocation; but the arm can be moved, passively, in certain direc- tions. Thus, the range of motion is most free in the upAvard dislocation ; Avhereas, in downward dislocation, under the acromion, the arm can be moved pretty freely backwards and forwards, but not outwards; and, Avith dislocation under the coracoid process, the arm cannot be moved iiiAvards and upAvards. Pain accompanies any opposed motion of the arm. Causes.—A fall on the shoulder Avould seem to be the usual, or only, occasion of these dislocations; the force being applied upon the top of the clavicle, to produce dislocation doAvnwards. Thus, in one instance, a horse trod upon the shoulder; and in another, the accident occurred to a child, from an attempt to support a great Aveight upon the top of the collarbone. Treatment.—Reduction is easily accomplished by draAving the shoulders backAvards and forwards, the Surgeon placing his knee between them, as recommended by Sir A. Cooper. Considerable difficulty will, hoAvever, be experienced in preventing the recurrence of displacement. A pad in m m 2 532 SPECIAL PATHOLOGY AND SURGERY. the axilla, and the application of a bandage, as for fractured clavicle; constitute the most effectual retentive apparatus. Direct compression is available only in dislocation upAvards. Many Aveeks should be allowed to elapse before this treatment is discontinued. Some deformity almost always remains, but Avith little loss of power in the movements of the arm. Dislocation of Both Ends of the Clavicle has been known to occur, simultaneously ; but it must be placed among the rarities of Dislocations. Dislocation of the Scapula.—The lower angle of the scapula some- times projects, apparently having slipped from under the edge of the latissimus dorsi muscle, which there crosses the scapula. I have seen one such case, on the right side. Any treatment is unsatisfactory, as the bone easily starts out of place again. Dislocations of the Shoulder-Joint.—These are the commonest of all Dislocations. The head of the humerus may undergo dislocation ; downwards, into the axilla, subglenoid; forwards, subcoracoid and sub- clavicular; backwards, on# the dorsum of the scapula beneath its spine, subspinous. These dislocations occur in the same order of relative fre- quency ; the first-named being by far the most common; the second, occasional; and the third, very rare. Subcoracoid dislocation has recently been regarded as the most frequent; Mr. Flower's investigations showing that of 41 specimens in the Museums of the London Hospitals, 31 are subcoracoid; and that in 50 cases known to him, 44 were of this form. Partial dislocation is said to occur; either as the subcoracoid, or a dislocation upwards, under the acromion. But the former dislocation is complete, the head of the humerus being lodged entirely out of the glenoid cavity, in the illustrative case given by Sir A. Cooper; the up- Avard dislocation is incomplete, the head of the bone lying partly in the glenoid cavity. Two such cases only are recorded, as having been veri- fied by dissection; one by Mr. John Soden, jun., of Bath, in the " Medico- DISLOCATIONS OF THE SHOULDER-JOINT. 533 of the subscapular muscle near its insertion into the small tuberosity. The muscles attached to the great tuberosity are stretched or torn, particu- larly the supra-spinatus; and, possibly, the tuberosity itself may be detached. The axillary vessels and plexus of nerves suffer compression by the head of the bone. Fig. 163. (2) Dislocation forwards, and subclavicular ;—the head of the hu- merus lies under the pectoral mus- cles, on the inner side of the cora- coid process, just below the clavicle (Fig. 168), and resting on the second and third ribs. The capsule may be completely separated from the neck of the bone; the loAver scapular muscles much torn, namely, sub- scapularis detached from the smaller tuberosity, infra-spinatus and teres minor from the great tuberosity; and possibly, this prominence of bone may itself be torn away from the head of the humerus. The axillary vessels and nerves suffer compression. (3) Dislocation backwards, or subspinous ; the head of the humerus lies just behind the glenoid cavity on the dorsum of the scapula, below its spine (Fig. 169), and between the infra-spinatus and teres minor muscles. The capsule is ruptured, and the muscles in front of the joint are stretched or torn; namely, the and Fig. 169. subscapularis, supra-spinatus, long head of the biceps. Partial dislocation upwards pro- duces structural alterations, but less extensive. In both the cases already noticed, the head of the humerus was partly dislodged up- wards, under the acromion; the capsule was slightly ruptured, and the long tendon of the biceps thrown out of its groove inwards, on to the smaller tuberosity of the humerus. Signs.—Certain signs are com- mon to all three, ordinary, disloca- tions of the shoulder. These signs are—flattening of the shoulder, ex- ternally ; a depression below the acromion, OAving to the absence of the head of the bone, and a corre- sponding projection of the acromion above (Fig. 170) (see Fig. 156); the presence of the head of the bone in an abnormal situation, downwards, forwards, or backAvards; some immobility, and inability to use the arm, and pain, particularly Avhen the arm is moved. But, the direction of the 531 SPECIAL PATHOLOGY AND SURGERY. axis of the humerus or arm, and the length of the arm, and the situation of the head of the bone, are distinctive in each form of dislocation ; thereby determining its diagnosis. " Fig. 170. Dislocation downivards into the axilla, is accompanied with some in- clination of the arm outwards, in a line Avith the trunk, and neither back- wards nor forAvards; an elongation of the arm is observable, or can be ascertained by measurement,—taking the apex of the acromion as a fixed point above the joint, and the external condyle of the humerus below. The head of the humerus can be felt in the axilla. Dislocation forwards or subclavicular, is distinguished by a direction of the arm backwards, and someAvhat outAvards; with some shortening. The head of the bone cnn be felt under the clavicle. Dislocation backwards or subspinous, is characterized by a direction of the arm forwards, and somewhat outwards, or occasionally, it hangs by the side ; with some shortening. The head of the bone can be felt under the spine of the scapula. Partial dislocation upwards—in the case recorded by Mr. Soden— was characterized, principally, by the position of the head of the bone, which appeared to be drawn higher up in the glenoid cavity, and un- naturally prominent in front; abduction produced a sensation of crepitus, the humerus rubbing under the acromion, and becoming locked as the arm Avas raised; and severe pain Avas experienced by any action of the biceps muscle. The Diagnosis of shoulder-joint dislocation as compared Avith fractures of the neck of the humerus, may be determined by the presence of the signs common to all these dislocations, and the absence of true crepitus. Atrophy of the deltoid muscle, resulting from contusion or other injury, simulates dislocation only by the flattening of the shoulder, and the over- hanging acromion. DISLOCATIONS OF THE SHOULDER-JOINT. 535 Causes.—Direct violence, as a fall on the shoulder, in the direction opposite to the particular form of dislocation. Thus, a fall from a height on the top of the shoulder may occasion dislocation doAvmvards ; and a fall on the front of the shoulder has been known to produce dislocation backAvards, or collision of the front of the shoulder against a tree, in the case of a person throAvn from a horse. Indirect violence applied to the arm Avhen itself in a position favourable to the particular form of disloca- tion. Thus, forcible abduction of the arm may occasion dislocation dowmvards ; and I have known it produced, as a recurring dislocation in an elderly gentleman, by merely resting the fingers on a chest of drawers, the arm being fully extended. Violent contraction of the deltoid in lifting a heavy Aveight, has also tilted the head of the bone doAvnwards, out of the glenoid cavity. A fall on the elbow, the arm being directed backwards, may occasion dislocation forwards; and dislocation backwards has been produced by pushing a person violently, with the arm eleArated. Spasmodic contraction of the muscles during an epileptic fit, was the cause of one such dislocation, in a case examined after death by Mr. Key. The causative relation of shoulder-joint dislocations to each other, is Avorthy of notice. Dislocation forwards—subclavicular—may result as the completion of a subcoracoid displacement, which is then regarded as a partial dislocation forwards. Or, the subclavicular dislocation may, it is said, be consequent on dislocation downwards. Sir A. Cooper regarded the former as a jirimary dislocation ; other eminent surgeons, for example, Desault, Petit, Dupuytren, Mr. Hey, and Professor Samuel Cooper, did not deny the possibility of its being primary; but they believed it to be very seldom so, and almost always secondary to dislocation dowmvards. Unreduced dislocation of the shoulder-joint is followed by the sIoav formation of a neAV articulation, and destruction of the glenoid cavity ; with proportionate recovery of the use of the arm. Thus, in an old dis- location dowmvards—described by Sir A. Cooper—the head of the bone had become flattened, and a neAV shallow cavity had formed for the recep- tion of the head on the inferior costa of the scapula anteriorly, a complete capsular ligament also surrounding the head (see Fig. 157) ; Avhile the glenoid cavity Avas entirely filled with ligamentous matter, in which were suspended small portions of bone, evidently of new formation, as no portion of the scapula or humerus AAras broken. Reduced dislocation is folloAved by good recovery of the use of the arm; some weakness only of the shoulder-joint remaining, Avith increased liability to dislocation. Aggravated by its recurrence, the looseness of articulation ultimately may be such that dislocation occurs on the slightest occasion of force in the right direction. In the case already alluded to of an elderly gentleman, dislocation doAvnwards into the axilla had been overlooked by an Hospital Surgeon in attendance for three Aveeks ; and, after reduction by Sir William Fergusson, it occurred four times in a period of eighteen months. Upward motion of the arm ay as after Avards restrained by wearing a belt around the chest, attached to an arm-loop, and the dislocation has not since returned. Treatment.—Reduction may be effected in various ways :— (1) By direct extension and counter-extension. This method is perhaps most generally applicable. The patient being seated in a chair, a sheet or jack-toAvel is draAvn under the axilla on the dislocated side, around the chest over the opposite shoulder, and attached to some fixed, resisting object, or held by assistants. Extension is made from the arm 536 SPECIAL PATHOLOGY AND SURGERY. Fig. 171. or wrist, by means of a linen band fastened by a clove-hitch knot. The arm should be drawn out at a right angle to the chest, and extension slowly maintained, by an assistant, or by pulleys, when necessary. (See Fig. 160.) The Surgeon placing his knee in the axilla, and depress- ing the shoulder Avith one hand, while he slightly inclines the arm down- wards with the other ; the head of the bone passes into the glenoid cavity with a jerk or snap, announcing the reduction. Extension is discontinued, and the arm brought to the side should be secured by a few turns of a roller around the chest, supporting the elboAv by a feAv turns beloAV. An axillary pad may be advisable in dislocation doAvmvards. Any inflam- matory swelling about the joint will subside, or can be readily subdued by cold evaporating lotions. I have thus reduced nearly all the disloca- tions of the shoulder which have fal- len to my lot. But the inconvenience of this method in private practice, is the assistance requisite, despite the relaxing influence of chloroform, and its administration Avould necessitate having another assistant. (2) By the knee in the axilla, reduction can be effected without extension; simply by drawing the arm well down over the knee, as a fulcrum, depressing the shoulder, at the same time, Avith the other hand. This was one of the methods recom- mended by Sir A. Cooper. (Fig. 171.) The patient lying recumbent, the (3) By the heel in the axilla. Fi«. 172. Surgeon sitting on the edge of the couch, plants his foot well up into the DISLOCATIONS OF THE SHOULDER-JOINT. 537 axilla, and drawing the limb well doAvn wards, inclines it imvards across the foot as a fulcrum. This also Avas another method employed by Sir A. Cooper. (Fig. 172.) (4) By raising the arm.—The patient lying recumbent, the Surgeon sitting behind the shoulder and fixing it Avith one hand, raises the arm up perpendicularly ; then bringing it down suddenly to the side, the head of the bone may snap into place. (Fig. 173.) Fig. 17;;. (5) Dislocation backwards may sometimes be readily reduced by bending the arm backwards, and, at the same time, draAving forward the upper end of the humerus, with the other hand. Unreduced dislocations of the humerus are to be overcome by one or other of these methods; generally, by direct extension and counter-exten- sion, under the influence of chloroform; aided, perhaps, by pulleys for making extension, which should be slowly maintained. Dr. Jarvis's " adjuster" has proved effectual Avhen other means have failed. Its prin- cipal advantage is that during extension, the limb can be moved about freely in all directions, Avithout relaxing the extension. The periods after dislocation when reduction has been accomplished, vary as to their extreme duration ; a month, in one of my own cases ; after tAventy-five Aveeks, by Mr. Brodhurst; after seven months, and ten months and a half, by Mr. Smith, of the United States. Dieffenbach accomplished the reduction of a dislocation fonvards after two years' duration; but not until he had cut the tendons of the pectoralis major, latissimus dorsi, teres major and minor, and had divided the ligaments surrounding the neAV joint. The extreme period for the safe reduction of dislocation is probably best determined by observing the movements afforded by the new joint; and Avhich indicate also the probable utility, or otherAvise, of reduction, although itself practicable. .J ccidents, of a most serious character, are liable to happen in the reduction of old standing dislocations ; laceration of the muscles and tendons, rupture of the axillary vessels and nerves, or fracture of the neck of the humerus. These lesions may occur apart from any inconsiderate application of extending force. Compound dislocation of the shoulder-joint is a rare form of injury. 53S SPECIAL PATHOLOGY AND SURGKRY. Erichsen mentions having seen two cases, and in two directions, of disloca- tion ; inwards—sub-coracoid, and—doAvnwards—sub-glenoid ; to Avhich may be added one more, into the axilla, as recorded by Hamilton among his own cases; and a compound dislocation of the shoulder by Sir A. Cooper. Treatment.—Reduction Avas effected in both Mr. Erichsen's cases, and they did Avell. The question of amputation must be determined by reference to the considerations Avhich render the sacrifice of the limb inevitable in Compound Dislocation, generally; and principally, regard- ing the injury to the axillary vessels and nerves. Dislocation, with Fracture of the Humerus, its Neck or Shaft. (See Fig. 107.) Some such cases are recorded by Hamilton. Their treatment is the only peculiarity of practical importance ; as to whether the dislocation, or the facture, should be reduced first? The former manipulation can, generally, be accomplished without much dif- ficulty. Extension will hardly avail much, or indeed be necessary, in effecting reduction of the dislocation. Pressure on the head of the bone, aided by the relaxing influence of chloroform, has proved quite sufficient. Failing in this way ; the fracture may be reduced and put up firmly, thus alloAving of extension, or one of the other methods for reduction of the dislocation. Failing still to reduce the dislocation, the fracture must be alone regarded ; and then at the earliest period after union of the fragments, reduction of the dislocation should again be attempted. This latter was the rule of treatment at one time, and it led to many success- ful results. But, it implied that Avhich experience has since disproved, the impossibility of reducing these complicated dislocations until the frac- ture had united. Congenital Dislocations of the Shoulder-joint.—Three varieties are recognised by Guerin; dislocation of the head of the humerus downwards ; doAvnwards and inwards, the head of the bone resting against the ribs; and subluxation upwards and outwards, the head of the bone sliding in this direction, favoured by a corresponding displacement of the coracoid and acromion processes. Dr. Robert Smith has met with only two forms of congenital dislocation of the humerus, sub-coracoid and sub-acromial ; of the former he has seen several examples. These dislocations, arising from either a paralytic condition of the muscles, or from developmental imperfections of the articulation, are necessarily incurable. Dislocations of the Elbow.—This joint is liable to eight recognised dislocations; four of Avhich relate to both bones; one to the ulna alone, and three to the radius alone. Thus (1) dislocation of both bones back- wards ; (2) outAvards; (3) imvards; (4) forAA'ards; (5) dislocation of the ulna alone, backAvards; (6) dislocation of the radius alone, back- wards ; (7) forwards; (8) outwards. To these recognised dislocations may be added another; dislocation of both bones outwards, and upAvards laterally on the humerus, constituting an " external latero-angular dis- location " of the elbow-joint, as I so named this form of dislocation, in the only instance I have ever seen or can find recorded. (See Fig. 161.) Structured Conditions.—(1) Dislocation of the radius and ulna back- wards, is the most frequent form. The head of the radius is lodged behind the external condyle, and the coronoid process of the ulna lies in the olecranon fossa ; the loAver end of the humerus resting on the anterior surface of the radius and ulna (Fig. 174). All the four ligaments are ruptured, leaving only some of the fibres of the internal lateral one. The DISLOCATIONS OF THE ELBOW. 539 annular ligament remains entire. The brachialis anticus and biceps muscles are stretched or torn, the former sometimes carrying away a portion of the coronoid process; but the other muscles are relaxed, the triceps posteriorly, and all the muscles originating from either condyle of Fig. 171. the humerus, excepting the supinator radii brevis. The median nerve is pressed forAvards by the humerus; and the ulnar nerve is, sometimes, painfully stretched over the projecting extremity of the ulna backwards. (2) Dislocation of the radius and ulna outwards, or to the radial side (Fig. 17;")), is far less frequent than the foregoing, and usually incomplete ; com- plete dislocation having been known to occur in only 11 cases. Incomplete dislocation; the ulna still articulates with the humerus, but the great sigmoid cavity is carried outAvards from the trochlea, so that is central crest rests upon the depression Avhich separates the condyle from the trochlea. If the annular ligament remains unbroken, the radius is displaced in the same direction and to the same ex- tent, its head resting against and directly below the outer condyle. More complete dislocation may occur, and complete dislocation, rarely ; the head of the radius being perhaps, thrown forwards or back- wards. A variety of this dislocation, is outAvards and upwards or backwards; the olecranon process of the ulna lying above and behind the outer condyle. The new variety, to Avhich I have alluded, is a complete dislocation of the radius and ulna outwards and upwards laterally; the large sigmoid cavity of the ulna embracing the outer condyle and capi- tellum, just behind its articular surface, at a right angle, externally, Avith the humerus; and the head of the radius above, being in close relation to the external ridge of the humerus, which (ridge) bisected its round cup-like cavity. The head of the radius, there- fore, Avas neither Avholly in front nor behind the humerus; it was not dislocated fonvards or backAvards. In outward dislocations, the ligaments are more or less completely torn; but, in the ordinary forms of such dislocation, the brachialis an- ticus and anconeus are the only muscles much disturbed, the biceps and 510 SPECIAL PATHOLOGY AND SURGERY. Fi«. 176. triceps traversing the articulation a little more obliquely ; Avhile the prin- cipal arteries and nerves do not suffer much, if at all. In the variety which I have described, the state of the muscles is also fully noticed with the arteries and nerves; of which the latter structures had singularly escaped injury.* (3) Dislocation of the radius and ulna inwards —or to the ulnar side — is much more rare than dislocation outAvards, and always incomplete, no example of.complete dislocation inwards having been recorded. The ulna is driven over the ele- vated inner ridge of the trochlea, and falls down on the inner condyle, or epi-trochlea, embracing it instead of the trochlea; Avhile the head of the radius, passing imvards also, occupies the trochlea. (Fig. 176.) The head of the radius is, gene- rally, in the same line Avith the ulna; but it may be found a little forwards or backAvards. A variety of this dislocation, is inwards and upwards or backwards; the coronoid process of the ulna being thrust upwards above the inner condyle, and the head of the radius occupying the olecranon fossa. The ligaments and muscles suffer some injury, and the ulnar nerve is peculiarly liable to con- tusion between the olecranon and inner condyle. (4) Dislocation of the radius and ulna for- wards, Avas considered impossible Avithout a frac- ture of the olecranon, this opinion having been taught by Sir A. Cooper and Vidal (de Cassis); but, Monin, Prior, Velpeau, Canton, and Denuce have each reported one example—five in number. The structural condition of this dislocation requires further elucidation. In Velpeau's case, the head of the radius rested in the coronoid fossa, and the olecranon was carried upwards and a little outAvards; whereas in Mr. Canton's case, as depicted in Hamilton's work, the olecranon rested, apparently, on its sum- mit against the forepart of the articular surface of the hume- rus, and the head of the radius was free lower down in the smaller sigmoid cavity of the ulna; thus constituting a com- plete dislocation of both bones forwards. (5) Dislocation of the ulna alone, backwards, seldom happens without some dislocation of the head of the radius; yet it is pos- sible that the coronoid process may pass backwards into the Fig. 177. * British and Foreign Med.-Cliir. Review, Jan., 1866. DISLOCATIONS OF THE ELBOW. of] olecranon fossa, (Fig. 177, an old unreduced dislocation. A. Cooper.) In one recorded dissection of such dislocation, observes Professor Pirrie, the coronary, oblique, and part of the interosseous ligaments were torn ; the brachialis muscle was stretched under the humerus, and the triceps much relaxed. (6) Dislocation of the head of the radius alone, backwards.—This dis- location (Fig. 178), is of rare occurrence, only 28 supposed examples having been collected. One only has been verified by dissection, and this is reported by Sir A. Cooper. The head of the radius Avas behind the external condyle of the humerus, and rather to the outer side. The coronary ligament was torn through at its forepart, and the oblique had given way. The capsular ligament was partially torn, and the head would have receded much more, but it Avas supported by the aponeurotic fascia. Incomplete dislocation, as occasionally happens in children, may not be attended with rupture of the annular ligament. (7) Dislocation of the head of the radius alone, fonvards—is relatively more common than backAvard disloca- tion. The head of the radius lies in front of the humerus, and gene- rally someAvhat outAvards. (Fig. 179.) The anterior and external lateral ligaments, with the annular, are, generally, more or less torn. Sometimes, the tAvo former are alone broken, the annular ligament also being sufficiently stretched to allow of complete dislocation ; or, the anterior and annular having given Avay, the external lateral remains intact. (S) Dislocation of the head of the radius alone, outwards—is generally a modification of, if not consequent on, fonvard dislocation, or, perhaps, backward dislocation. The head rests on the outer side of the external condyle. Signs.—Certain characters are common to all dislocations of the elbow a resemblance Avhich renders it convenient to take these injuries con- secutively, in regard to their signs, as shoAving more clearly their diagnosis. Dislocation of the radius and ulna, backwards, presents a projection of the elbow posteriorly—corresponding to the extremities of both bones, and of the olecranon in particular; Avith another projection, the end of the humerus in front of the elbow. (Fig. 180.) There is also some shortening of the forearm, semi-flexion, approaching to a right angle 542 SPECIAL PATHOLOGY AND SURGERY. occasionally, and semi-pronation; with loss of the motions of flexion and extension, pronation and supination, but an unnatural lateral motion can generally be produced. Fig. 180. Fig. 181. Dislocation of the radius and ulna, outwards, is characterized by an unnatural projection externally—the head of the radius, with a prominent projection internally—the inner condyle; while dislocation of the radius and ulna inwards, is distinguished by the opposite characters—a projec- tion internally of the olecranon, and prominence externally of the outer condyle. The forearm is shortened; on its inner aspect in outward dislocation, and on its outer aspect in inward dislocation; or the whole forearm is shortened, in either of these dislocations upwards. In both, there is also semi-flexion, and semi-pronation. Dislocation of the radius and ulna forwards, Avould seem to be characterized, by disappearance of the olecranon posteriorly, and the detection of this process and the head of the radius in front of the elbow; with shortening of the fore- arm upon the arm, semi-flexion to a right angle, and marked supina- tion. If accompanied Avith fracture of the olecranon, there will be some mobility and crepitus. Dislocation of the ulna alone, backwards, would probably be recog- nised by projection of the olecranon, the head of the radius being felt to rotate in its place ; by the inclina- tion of the forearm to the ulnar side, with partial flexion, and complete pronation. If accompanied with fracture of the coronoid process, there will be considerable mobility, the dislocation readily disappearing and recurring, with crepitus. Dislocation of the radius alone, backwards, is characterized by a pro- jection of the head of the bone be- hind the outer condyle, where it can DISLOCATIONS OF THE ELBOW. 543 be felt to rotate; Avhile dislocation forwards, is distinguished by a pro- jection of the head of the bone in front of the humerus. In both disloca- tions, the forearm is shortened slightly on its outer side, and inclines to that side, with slight flexion, and pronation. (Fig. 181.) But the latter form of dislocation is distinguished by the position of the head of the radius, and the impossibility of flexing the forearm beyond a right angle, Avhere the head of the bone impinging on the humerus brings this motion sud- denly to a deadlock. This peculiarity was first shown me, when a student, by Mr. Morton, in a case many years since at the University College Hospital; and it was a well-marked sign in another case under my own observation and treatment at the Royal Free Hospital, Dislocation of the head of the radius, outwards, may be recognised chiefly by the position of the head on the outer side of the external con- dyle, immediately under the skin, Avhere it can be felt to rotate. Causes.—Indirect violence is, probably, more commonly the cause of all these dislocations. Thus, a fall on the hand may drive both bones backwards; possibly, outwards or inwards; the ulna alone backwards; or the radius alone backwards or forwards. But the position of the forearm, with regard to pronation or supination, Avill also affect the direction of the dislocation. Thus, the former position facilitates dislo- cation of the radius forwards; and a vuolent effort to supinate the fore- arm, while it is grasped and held firmly in a state of pronation, will occasion dislocation of the radius backwards. TAvisting or Avrenching of the forearm, as by machinery, may also occasion dislocation of both bones outwards or inwards; and less probably of either bone, the radius, in particular, backAvards or forwards. The latter dislocation of this bone has been produced in children, by lifting the child suddenly from the floor by the hand, or an attempt to sustain the child when about to fall. Direct violence may also be the cause of most forms of elboAV-joint dislocation. Thus, both bones may be throAvn backwards, by a blow upon the back and lower part of the humerus; or on the front and upper part of the forearm; or the bones are usually thrown outwards or imvards, by a blow on the side of the arm or forearm opposite to the direction of dislocation; and, in like manner, the radius alone has been started back- Avards, by a blow upon the front and upper part of that bone; or for- wards, by a bloAv upon the back of the head of the radius. Two dislocations of the elboAv, I have omitted to notice, in thus de- scribing the etiology of these injuries. Dislocation of the radius and ulna forwards, is, however, too rare an accident to be included in any general statement. In Velpeau's case, the man Avas knocked doAvn by a carriage, the Avheel passing over his right arm. Dislocation of the head of the radius, outwards—the other exceptional form of injury—is a modification of, or consecutive to, dislocation of that bone, forwards or backAvards. Unreduced elboAV-joint dislocations are, probably, no exception to the pathological law of Dislocations in general; that the bones gradually adapt themselves to the particular displacement, forming a neAV articu- lation ; with more or less recovery of the use of the limb. An unreduced dislocation of both bones backwards, and of seven years' duration, is depicted in Liston's Surgery. The movements of the hand were consider- ably regained. The structural condition acquired in such cases remains to be shown by dissection; no opportunity, I believe, having hitherto offered for this purpose. Reduced dislocations of the elbow generally result in a complete recovery of the use of the joint, Avithin a feAv weeks. 544 SPECIAL PATHOLOGY AND SURGERY. But in one of seAreral exceptional cases under Hamilton's observation, a dislocation of both bones backwards was easily and promptly reduced in a lad eight years old ; yet, six months afterwards, the arm had become bent to a right angle, and quite stiff at the joint. Four years later, the stiff- ness still continued with only slight improvement. Treatment.—Reduction of all the dislocations to Avhich the elboAV-joint is liable, can be effected by the same method—bending the elbow over the knee—but those of the radius are, perhaps, better accomplished in another way. (1) Bending the elbow over the knee, Avas the method recommended by Sir A. Cooper. The patient being seated on a Ioav chair or stool, the Surgeon resting one foot on the seat, places his knee in the bend of the dislocated joint; grasping the forearm, he presses the knee against the inner side of the forearm to unlock the ulna from behind the humerus, and drawing or bending the forearm round the knee, the bones readily come forward over the articular end of the humerus, into position. The action of the muscles will, in fact, effect reduction, when the bones are dislodged. Another method, which seems to be a modification of the preceding, Avas that recommended by Boyer. Extension is made from the wrist by one assistant, the forearm remaining at a right angle Avith the arm, while counter-extension is made by another assistant holding the arm; the Surgeon grasping the elbow with both hands, presses the olecranon process downwards and forAvards. This method does not so readily unlock the bones, and extension from the Avrist tells more upon the radius than the ulna, which chiefly opposes reduction. It is, therefore, preferable to grasp the middle of the forearm with both hands, and draw it forwards ; no assistant being required except, perhaps, to steady the arm. (2) Dislocations of the radius alone, may be reduced by straight extension gradually from the Avrist, the arm being fixed ; aided by pressure on the head of the bone fonvards or backwards, according to the dislocation. In backward dislocation also, forcible supination will aid in just throAving the head of the bone forAvards over the articular surface of the humerus; while, in forward dislocation, forcible pronation will similarly jerk the head into place. But these movements are useless until the head lies on the brink of reduction, and unless while extension is still being continued. After reduction has been effected, it should be maintained by the application of a right-angled splint upon the back of the arm and fore- arm, with a compress over the head of the bone—in the case of radial dislocations ; and the forearm supported in a sling. The period for re- moval of this retentive apparatus should be regulated by the liability to re-dislocation, and to stiffness of the joint. Dislocation Avith fracture, as of the coronoid or olecranon process of the ulna, may be treated in the same way; but retention of the bone in position must be continued for some weeks. Unreduced Dislocations of the Elbow, are curable or incurable; partly according to their duration, principally hoAvever with reference to the form of dislocation. Recent dislocation of the ulna or involving the ulna is much more difficult of reduction, than that of the radius after a long period; the difference being due to the irregular form of the head of the ulna which opposes reduction. Dislocation of the radius alone has been reduced at periodr, varying from a few days to weeks or months. In one DISLOCATIONS OF THE INFERIOR RADIO-ULNAR ARTICULATION. 545 instance I reduced a dislocation backwards, of ten weeks' duration, and the patient, a laundress, recovered good use of her forearm. Dislocation of the radius forwards, has remained unreduced in the hands of skilful Surgeons. Sir A. Cooper failed in two recent cases; and of the six which came under his immediate observation, only two were ever reduced. Malgaigne states that in a collection of 25 cases, efforts at reduction were ineffectual in 11, and the accident was unrecognised or neglected in 6 ; leaving only 8, of the whole number, reduced. The golden rule should be observed in elbow-joint dislocations, as in all other such injuries, not to interfere when the motions of the joint are tolerably efficient. Compound Dislocations of the Elbow.—These injuries are always perilous; both on account of their nature, the size of the joint, and as being caused by considerable violence. (Fig. 182.) The " external-latero angular " dislocation, Avhich I have described, was compound, and produced by a wrench of the forearm between the buffers of tAvo railway carriages. Treatment.—These compound injuries present nothing peculiar in relation to their treatment. The preservation of the limb, or operative interference, by excision or amputation, must be guided by similar con- siderations to those which relate to shoulder-joint dislocations, or to such injuries in general. Congenital dislocations of the elbow have been met with, in the form of both bones backAvards, or as pertaining to the head of the radius. These imperfections are more curious pathologically, than interesting surgically. Dislocations of the inferior radio-ulnar articulation.—The head of the radius in its relation to the smaller sigmoid cavity of the ulna, constituting the superior radio-ulnar articulation, may undergo dislocation in the directions already described, as dislocations of the head of the radius,—backAvards, forwards, or outwards. The lower end or head of the ulna in its articulation with the loAver end of the radius, is liable to dislocation, backAvards or forAvards. (1) Dislocation backivards, is characterized by an unnatural promi- nence of bone—the head of the ulna, at the posterior and inner part of the wrist, Avith loss of the motions of pronation and supination. In connexion with fracture of the loAver end of the radius, this dislocation is not very uncommon; alone, it seldom occurs, 11 or 12 cases only having been collected by Malgaigne. The cause Avould seem to be violent pronation. Thus, Desault re- cords the case of a laundress Avho in Avringing a Avet sheet, produced dis- location of the head of the ulna backwards. N N 546 SPECIAL PATHOLOGY AND SURGERY. Treatment.—Reduction can be readily effected by forcible supination of the forearm, with pressure on the head of the ulna forwards. Gene- rally the bone remains in place without further assistance ; or it may be necessary to apply a compress and splint. (2) Dislocation forwards is denoted by a projection of the head of the ulna at the anterior and inner part of the wrist; the natural prominence of this portion of the bone at the back of the wrist having disappeared. The motions of pronation and supination are lost. This dislocation is even more rare than the former; 9 cases only having been collected by Malgaigne, to which Hamilton adds 1 more, as reported by Parker, of Liverpool. The cause is apparently, with hardly any exception, violent supination of the forearm. And this mode of production throws light on the com- paratively less frequent occurrence of this dislocation ; the motion of supi- nation being less extensive than that of pronation, and less likely to be excessive in any of the offices which the hand has to perform. Treatment.—Reduction is easily effected by forcible pronation of the forearm, Avith pressure on the head of the ulna backwards. Redislocation need not be apprehended. There was no such tendency in Mr. Parker's case. Dislocations of the Radiocarpal articulation, or Wrist-joint.— This articulation may undergo dislocation backwards, or forwards. (1) Dislocation of the hand and carpus, backwards, presents a large projection, the carpus at the back of the wrist, and another, the lower Fig. 183. end of the radius and ulna on the palmar aspect (Fig. 183 and Fig. 184) ; with flexure and immobility of the hand. (2) Dislocation of the hand and carpus, forwards, presents just the opposite appear- ances ; a projection of the carpus in front of the wrist, and of the radius and ulna on the dorsal aspect (Fig. 185), with extension and immobility of the hand. Causes.—A fall on the hand is the usual occasion of dislocation; DISLOCATIONS OF THE CARPAL BONES. 547 the back of the hand, probably, receiving the force of the shock in backward dislocation of the carpus; and the palm of the hand receiving the force in forward dislocation. These dislo- cations are usually said to arise conversely; but the cases de- scribed in Hamilton's work ap- pear to clearly disprove the ac- cepted representations in most surgical works. Treatment.—Reduction can generally be effected in either form of dislocation by extension and counter-extension ; posi- tion should then be maintained by antero-posterior splints secur- ing the hand. Injuries of the Wrist allied to Dislocation.—(1) Dislocation, with fracture of the loAver end of the radius, happens far more commonly than dislocation alone. The diagnosis will turn on the presence of crepitus and mobility of the lower fragment, as determined by moving the hand, at the same time feeling whether the styloid processes of the radius and ulna move with it. Dislocation with fracture of the posterior margin of the articulating surface of the radius, is known as " Barton's fracture." Some difficulty may be experienced in keeping the bones in place. (2) Fracture of the lower end of the radius may be mistaken for dislocation of the wrist; but it can be distinguished in like manner. The comparative frequency of the former injury and rarity of the latter, led Dupuytren to almost deny the possibility of radio-carpal dislocation; though the occurrence of this dislocation is now established beyond a doubt. (3) Fracture with impaction of the fragments is unattended with the usual fracture signs, mobility and crepitus; but it may be distin- guished from dislocation, chiefly, by the resistance offered to reduction. (4) Sprain, also, simulates dislocation: here, however, the swelling is single, and not Avell defined, like the bony projections of dislocation; it does not appear immediately, and gradually increases. Compound Dislocation of the Wrist. This accident is of rare occur- rence. One case only has been seen by Hamilton, and one recorded by Sir A. Cooper. As associated with fracture, the injury may happen more frequently. Always a serious injury, compound dislocation is even more so in consideration of the violence Avhich causes it. Treatment.—The amount of damage done to the soft textures and to the bones, Avill guide the Surgeon respecting the probability of preserving the hand, or the necessity for excision or amputation. Congenital dislocations of the wrist, are described by Guerin as, pos- sibly, occurring in three forms; forwards, backAvards and upwards, backAvards and outAvards. These dislocations are connected Avith, and dependent on, imperfect conditions of the radio-carpal articulation, or incomplete paralysis of the muscles of the forearm and hand. Dislocations of the Carpal Bones, among themselves.—Simple dislocations or rather subluxations of the carpal bones take place, it is said, occasionally; but, perhaps, only in one direction—backwards. N N 2 548 SPECIAL PATHOLOGY AND SURGERY. The bones thus liable to dislocation are; the semilunar, cuneiform, and pisiform bones of the first row, and the os magnum of the second row, which is most frequently displaced. Dislocation of any of the carpal bones may occur, in connexion with gunshot injury, or other occasions of extensive fracture of the neighbouring bones. The Signs will be; a bony projection at the back of the wrist, Avith some loss of power. The Cause is usually a fall on the back of the hand, which being thus forcibly doubled under itself, occasions one of the carpal bones to start backwards ; the os magnum, for example. Treatment.—Pressure may easily replace the bone, but the application of a compress, and for some time, will be necessary, to guard against redislocation ; the os magnum, in particular, having a great tendency to slip out again. Dislocations of the Metacarpal Bones at their Carpal articulations. —Any such dislocation is rare, and usually limited to a single metacarpal bone, backwards. The thumb is most commonly dislocated, and either backwards or forwards on the trapezium; the former displacement oc- curring more frequently. The Signs, in any case, are sufficiently obvious; projection of the end, or base, of the metacarpal bone, in the direction of displacement, and immobility. Causes.—A fall on the thumb bending it on itself, represents the ordinary mode of its dislocation. A blow upon the extremity and palmar aspect of the last phalanx may, however, cause dislocation; the force then acting in the opposite direction, or from within outwards. Treatment.—Extension, with pressure on the end of the bone, will generally succeed in effecting reduction. A splint should then be ap- plied, and perhaps a com- press to prevent any risk of redislocation. The bulky base of the meta- carpal bone of the thumb sometimes obstinately re- sists reduction ; in which case, Sir A. Cooper re- commends that the dis- location should be left to acquire the compensatory motion of a new joint, rather than the Surgeon run any risk of injuring the nerves and blood- vessels, by dividing the muscles or ligaments. Dislocations of the first Phalangeal Bones —at the Metacarpopha- langeal articulations. — These dislocations, also, seldom happen; and usually, the bone is driven backwards (Fig. 186), though sometimes for- wards. (Fig. 187.) I have seen the phalangeal bones Fig. 186. Fig. 187. DISLOCATIONS OF THE FIRST PHALANGEAL BONES. 549 of the index and middle fingers partly driven back, in the left hand of a prizefighter. The first phalangeal bone of the thumb is most frequently dislocated, and either backwards, or forwards; the former displacement occurring more commonly. Hamilton has met with the backward dislo- cation seven times, the forward only twice. The Signs are characteristic; a projection of the posterior extremity of the phalangeal bone, in the direction of displacement, and immobility. The thumb presents somewhat peculiar appearances. Its first phalangeal bone, having slid backwards upon the metacarpal bone, stands off from this bone at an angle; thus allowing the head of the metacarpal bone to project prominently towards the palm of the hand; while the second or ungual phalangeal bone is flexed upon the first, and forms another angle in the thumb. The phalangeal bone is locked in its new position, and reduction may be proportionately difficult. This immediately arises either from the constriction of the neck of the bone between the lateral ligaments, as Hey believed; or between the two heads of the short flexor, as affirmed by Malgaigne, Vidal (de Cassis) and others; or from the interposition of the anterior ligament torn from its attachments and folded in between the 'joint, as alleged by Pailloux and many others. Displacement of the long flexor tendon inwards or outwards, so as to impede reduction, has been found by Lisfranc, Deville, and Wadsworth. Treatment.—Reduction can sometimes be accomplished easily ; by extension, inclining the finger toAvards the palm, with pressure on the displaced end of bone. (Fig. 188.) Or, the thumb may require more Fig. 189. poAverful traction ; as by means of a strong tape fastened on the phalanx Avith a clove-hitch knot (Fig. 189), care being taken to protect the skin by a piece of moist Avash-leather Avrapped round the part. Or pulleys may be had recourse to, applied in like manner. A more effectual mode of extension occasionally, is by means of a large door-key; Avhich, I believe, Mr. Liston originally sug- gested. Passing the ring of the key over the thumb, and hitching it against the projecting end of bone; extension and pressure can thus be brought to bear advantageously, and simultaneously. Before apply- ing any such extending force, reduc- tion may be facilitated by soaking the thumb for some time in Avarm 550 SPECIAL PATHOLOGY AND SURGERY. water, in order to relax the parts as much as possible; a very useful recommendation given by Sir A Cooper. Subcutaneous section of the opposing ligaments or tendons, should be resorted to as the last resource. It was employed successfully by Mr. Liston in a recent case—not an hour having elapsed, the patient an old man and very drunk; no resistance, apparently, to reduction existed, and very poAverful force had been applied and persevered in without avail. At last, the external lateral ligament was divided by the point of a very narrow and fine bistoury ; and then replacement became immediate and easy. Some inflammation followed, but was kept within bounds, and the man regained the use of the articulation. Dislocations of the Middle, and Ungual, Phalangeal Bones, occur even less frequently than dislocations of the first row. Their pathology, signs, and treatment, are similar. Compound Dislocations of the Bones of the Hand.—Those of the thumb are most common, as they are also the most serious and important with regard to the future use of the hand. But any such dislocation is usually connected with fracture, and extensive laceration of the palm. The causes of these injuries are always some occasion of extreme violence. The explosion of a flask of powder in the hand happens now and then, driving one or more of the bones backward, and otherwise shattering the hand. I have had to deal with two such accidents. Treatment.—Reduction can usually, be effected without difficulty ; the obstacles of ligaments or tendons having already given Avay as part of the injury. The wound should then be closed, and the joint fixed, as in ordinary compound dislocations. Generally, however, the extent of injury requires some operative interference. Excision of splintered portions of bone, or amputation of one or more fingers, may therefore become un- avoidable alternatives. The preservation of the thumb, and perhaps of the little finger with it, is always a consideration of paramount importance. This remnant hand will serve the useful purpose of a hook, or of prehen- sion by the conjunction of the thumb and finger. Congenital Dislocations of the Fingers.—The last three fingers of the left hand in a foetus examined by Chaussier, were found to be dislocated at the metacarpo-phalangeal articulation. The thighs, knees, and feet were also dislocated. The last two phalanges of the fingers are, M. Berard states, incurved backwards, occasionally, in newly-born children of the female sex ; and Malgaigne has himself seen a woman in whom from birth, all the phalangettes were carried backwards to an angle of 135°, leaving the heads of the phalanges projecting forward under the skin. Dislocations of the Pelvis.—(1) The Symphysis-pubis, and the Sacro- iliac Articulations ; may, severally, undergo separation and displacement. In one case, I found all three articulations completely separated, in a young man whose pelvis had been subjected to severe compression. The Signs of any pelvic disarticulation are sufficiently obvious; some deformity and mobility at the seat of injury. The cause of disarticulation is always some extreme violence, and generally a compressing force. Treatment.—The same as in fracture of the pelvis. (2) The Coccyx is more frequently bent or displaced than frac- tured. Such dislocation may be forwards, as the result of a fall; or backwards, in consequence of pressure by the head of the child during parturition. DISLOCATIONS OF THE HIP-JOINT. 551 Treatment.—The same as for fracture of the coccyx. Dislocations of the Hip-joint.—This joint is subject to four principal dislocations; and to five anomalous dislocations; resulting from the freedom of motion of the hip—as a ball-and-socket joint—in all directions. The number of possible dislocations may therefore be added to by increasing experience; any point in the circumference of a circle representing a direction in which dislocation of the hip might possibly occur, from the joint as a centre. Taking the four principal dislocations of the hip, in their order of frequency, they are as follow :— (1) Dislocation, upwards and backwards on the dorsum ilii; (2) up- wards and backwards into the great ischiatic notch; (3) downwards and forwards into the obturator foramen; and, (4) upwards and forwards upon the pubes. To these may be added, as anomalous and occasional disloca- tions; (5) Dislocation, directly upwards, between the anterior superior and inferior spinous processes of the ilium, or thereabouts; (6) down- wards and backwards, upon the posterior part of the body of the ischium, betAveen its tuberosity and its spine ; (7) downwards and backwards, into the lesser or lower ischiatic notch; (8) directly downwards, beneath the lower border of the acetabulum; (9) and, forwards, into the perineum. The first four-named dislocations severally require special consideration; but even their relative frequency is very different. Sir A. Cooper states that in 20 cases of hip-joint dislocation; 12 will be on the dorsum ilii, 5 into the sciatic notch, 2 into the thyroid foramen, and 1 upon the pubic bone. Dislocation upwards and backavards; (1) on the dorsum ilii, and (2) into the great Ischiatic Notch.—Structural conditions.—(1) The head of the femur rests on the Dorsum Ilii, or within the fibres of the deeper gluteal Fig. 190. muscles; and it is directed backwards, the great trochanter forwards. (Pig. 190.) The capsular ligament, and especially its posterior half, is lacerated, and the round ligament ruptured; the small external rotator muscles are stretched or rent completely asunder, and the glutaeus maximus, medius, and mini- mus torn up more or less in extent from the dorsum ilii; thus allowing the head of the femur to occupy its unnatural situation. The triceps adductor is put upon the stretch. The particular direc- tion of the head backwards and tro- chanter forwards, has been attributed to the strong anterior portion of the capsule which proceeds to the anterior inter- trochanteric line, still remaining entire; and thus resisting the action of the rotator muscles. Resistance to reduc- tion in this, and other dislocations of the hip, has been ascribed either to the rent capsular ligament entangling the head and neck of the bone; or to opposing muscles; or to both this ligament and the muscles. (2) Dislocation into the great Ischiatic Notch, corresponds so nearly 552 SPECIAL PATHOLOGY AND SURGERY. in its pathology, Avith that on the dorsum ilii, as to require only a diffe- rential description. The head of the femur lies in the great sciatic notch, behind and a little above, the acetabulum ; being situated between the upper margin of the notch above, and the sacro-sciatic ligaments below. (Fig. 191.) It rests upon the pyriformis muscle; or upon the gemelli and sacro-sciatic nerve, as in a case dissected by Mr. Syme. The attitude of the bone, and rupture of the ligaments and muscles, are very similar to the condition of dorsal dislocation. Fig. 191. Fig. 192. inch and a half as the average, to three inches occasionally ; the knee is slightly flexed, and the thigh upon the abdomen, thus projecting the knee forwards; there is marked inversion of the limb, the knee being directed inwards, as well as forwards, towards the other, and just above it, the foot also is inverted, so that the great toe rests on the opposite ankle. (Fig. 192.) The head of the femur in its new situation, with the gluteal muscles, give an unnatural prominence to the posterior aspect of the buttock, and the bone can be felt, especially on rotating the limb ; the prominence of the great trochanter is diminished, and drawn upwards and turned forwards near the anterior superior spinous process of the ilium. Immobility of the limb, at least in the direction of eversion, abduction, and extension, will be more or less complete ; and the patient has lost the power of such voluntary motion ; great pain also attends almost any movement of the limb. (2) Dislocation into the great sciatic notch, presents similar signs, but in a lesser degree ; thus rendering the charac- teristic appearances less marked. Shortening has taken place to an extent usually of half an inch, and not exceeding an inch. Flexion and inversion DISLOCATIONS OF THE HIP-JOINT. 553 Fig. 193. are such, that the axis of the dislocated thigh points the knee more across the opposite thigh, and the end of the great toe rests on the ball of the great toe opposite. (Fig. 193.) The hip appearances are less conspicuous; the head of the femur sinking into the hollow of the notch, and the great tro- chanter approaching less nearly to the anterior superior spinous process of the ilium. The diagnosis of these dislocations from other injuries is, generally, clear. Fracture of the neck of the femur ac- companied with inversion of the limb, is comparatively rare ; and Avhen it occurs, mobility and crepitus of the fragments will, usually, determine the diagnosis. Impacted fracture, however, Avith conse- quently an absence of these signs, is ahvays an equivocal condition. Two points of distinction betAveen dislocation of the hip upwards and backwards, and impacted fracture, are laid down by Erichsen ; that in dislocation, the head of the bone can be felt in its new situation by deep manipulation of the gluteal region ; and that the trochanter is dia- gonal in its relative position to the ante- rior superior spinous process, but, in fracture, it lies nearly in a perpendicular line Avith it. Disease of the hip-joint resembles dislocation upAvards and back- Avards, in its general characters ; and par- ticularly when advanced to the stage of shortening of the limb. The antecedent history of limping lameness and pain, before any such resemblance becomes established will sufficiently decide the diagnosis. Failing to recognise the nature of the case, instances have occurred of attempted reduction in hip-joint disease; a sad mistake, and which would sorely aggravate the disease. Causes.—The attitude of the limb at the time of dislocation is always most influential in this, as in other such injuries. When the body is bent forward on the thigh or the thigh on the abdomen, and the thigh in a state of adduction close to the opposite thigh ; hip-dislocation upwards and backAvards may, then, result from a fall on the foot or knee, and especially while the individual is carrying a load on the back; or from the fall of a heavy Aveight, as a mass of earth, upon the back of the pelvis, the body being much bent forAvards. Dislocation may thus take place either on the dorsum ilii, or into the great sciatic notch; but, to gain the latter situation, the limb must be in a position more nearly at a right angle Avith the trunk. Unreduced dislocation of the hip backAvards proceeds to the formation of a neAV joint; the pathology of Avhich may be regarded as the type of any such conqiensatory construction, and is, therefore, considered in the general history of Dislocation. Cases are on record shoAving the efficiency of the limb eventually, in a 554 SPECIAL PATHOLOGY AND SURGERY. state of unreduced dislocation; one—related by Hamilton—after nine years dislocation on the dorsum, where a young man could walk rapidly, although with a halt, yet without pain and discomfort; in another case, after only eight weeks' dislocation into the sciatic notch, the limb aa as quite useful. Reduction of dislocation on the dorsum, is, generally, followed by speedy recovery of the use of the limb; in the course of a few weeks or months at most, the limb becoming as sound and useful as before. The same may be said in favour of dislocation into the sciatic notch ; reduction soon restores the thorough efficiency of the limb. Treatment.—Chloroform should always be administered — unless specially contra-indicated—to relax the muscles. A warm bath may be substituted for the relaxing influence of chloroform, in exceptional cases. Reduction can then be effected in either of two ways; by extension and counter-extension of the limb, pulleys being necessary to overcome the muscular resistance and its duration, in most cases; or by flexing the limb on the thigh, and guiding it so into position, that the muscles them- selves, probably, complete the reduction—constituting the method by " manipulation." (1) Extension and Counter-extension.—The patient must be placed on his back, inclining to the side opposite to that of dislocation; and suf- ficiently raised from the ground on a bed or table, that the long axis of the thigh may be in a line with the force of extension, resisted by counter- extension, which should be applied in the following manner. (Fig. 194.) A padded belt is fastened round the lower part of the thigh, having a double strap attached to it, terminating in a ring; to the latter a multi- plying pair of pulleys, of three cords, is hooked, whereby extension is brought into operation; the distal pulley being hooked to a ring or staple driven into the wall or some firmly fixed object, in a line with the thigh. A padded perineal band, for counter-extension, must be secured in like Fig. 194. manner. An apparatus of this kind, and Avell adapted for the purpose, is manufactured by Messrs. Weiss. The cord of the pulleys may be en- trusted to an assistant, the Surgeon taking charge of the thigh and hip. Extension should be made slowly, gradually increased, and steadily main- tained. The great trochanter will be observed to descend and to come more into position, as extension proceeds; the upper part of the thigh should then be raised Avith one hand or by means of a towel passed under the thigh, in order to lift the head of the femur over the prominent brim of the acetabulum"; while at the same time rotating the thigh outwards, with the other hand, thus to incline the head of the bone downwards and DISLOCATIONS OF THE HIP-JOINT. 555 forAvards; it will, generally, be felt to slip in with a jerk, rather than a snap, the muscles being worn out beyond the power of any sudden con- traction. On relaxing the extension, the perceptible disappearance of the signs of dislocation, in the length of the limb, &c, announces the cer- tainty of reduction. The limb must then be retained in position, to guard against the liability of re-dislocation. A long splint and bandage, as for fracture of the thigh, has been recommended for this purpose ; but simply connecting the reduced limb with the sound limb, by means of a few turns of a bandage around the thighs side by side, I have always found to afford a sufficient security. The patient must remain in bed for ten days or a fortnight, during the reparation of the ligamentous and other tissues. Dislocation into the sciatic notch is accomplished in like manner, but with greater difficulty, owing to the imbedded position of the head of the femur. (Fig. 195.) Extension should be made across the middle of the opposite thigh, and the head of the bone more lifted out of its bed; the patient inclining more to the opposite or sound side. To effectually raise Fig. 195. the head of the bone, it is sometimes recommended, that a towel passed under the thigh, should be looped round the neck of an assistant, who stooping over the pelvis and pressing doAvnwards with both hands, raises his shoulders ; thus bringing considerable power to bear in drawing the bone forwards towards its socket. Manual extension may succeed, especially if aided by the influence of chloroform, in effecting reduction of hip-joint dislocation. This alter- native extending force is, therefore, a valuable resource in the absence of pulleys, which cannot always be at hand. I thus succeeded in reduc- ing a dislocation of the hip, on the dorsum ilii, and of twenty-four hours' duration, where also the belt and straps, Avhich were neAV and sound, had given Avay in using them. (2) Manipulation.—This method of reduction was known to Hippo- crates, and has since been variously practised by Surgeons in modern times; but, in 1851, Dr. W. W. Reid of Rochester, N. Y., so attracted the attention of the profession to this proceeding, as to have fairly intro- duced it as an established method of practice. Dr. Reid's method consists :—" In flexing the leg upon the thigh, carrying the thigh over the sound one, upwards over the pelvis as high as the umbilicus, and then abducting and rotating it outwards." Hamilton's description of the proceeding is this :—"The patient being laid on his back upon a mattress, the Surgeon—assuming that it is a dis- location on the dorsum ilii—should seize the foot Avith one hand and the 556 SPECIAL PATHOLOGY AND SURGERY. other he should place under the knee; then, flexing the leg upon the thigh, the knee is to be carefully lifted toward the face of the patient until it meets with some resistance; it must then be moved outwards and slightly rotated in the same direction until resistance is again encountered, when it must be gradually brought downwards again to the bed. We do not know that the whole process could be expressed in simpler or more intelligible terms, than to say, that the limb should follow constantly its own inclination." In attempting the reduction of dislocation into the sciatic notch, by manipulation, the same author warns us of the special danger, " that the head of the bone will be thrown across into the foramen thyroideum.'' " The following summary of a paper—prepared by Dr. Hamilton— with the view of determining, if possible, the relative value of the two methods—manipulation and extension—and exhibiting an analysis of 64 cases in which manipulation was employed, will enable the reader to form some estimate of the difficulty in which this subject is involved ; and if it does not actually decide a moot-point, it will at least demonstrate that the method by manipulation is not without its hazards. Of 41 cases in which the fact is stated, 28 were reduced on the first attempt, 7 on the second, 4 on the third, and 2 on the seventh. In 7 examples, the head of the femur has been thrown from one position to another upon the pelvis, travelling from the dorsum ilii to the ischiatic notch, and from thence to the foramen ovale; or directly from the dorsum to the foramen, and back again; or in other directions, according to the character of the original dislocation ; in some instances these changes being made as often as seven times in succession. In the majority of cases, no evil conse- quences seem to have followed upon these changes of position." Dislocation Downwards and Forwards into the Obturator Foramen.—Structural Condition. — The head of the femur lies in front of the obturator foramen, lodged upon the obturator externus muscle, the ball being directed inwards and the great trochanter outwards. (Fig. 196.) The cap- sule has given way, especially on its inner side, and the round ligament is torn from its attachment; but the constancy of the latter lesion is disputed. Signs.—This dislocation, also, presents very characteristic appearances. The limb is lengthened from one to two inches in extent, the knee bent, and the body inclined forwards—apparently to relax the painful tension of the psoas and iliacus muscles; and the whole limb is in advance of the other, and much abducted, the foot usually points forwards, but occasionally it is slightly everted. (Fig. 197.) The head of the femur can be felt in its new situation, particularly in thin persons; and the prominence of the great trochanter has dis- appeared entirely, presenting a marked flattening of the hip, or a depres- sion in the situation of the trochanter. Causes.—The limb must be in a state of abduction, at the moment of DISLOCATIONS OF THE HIP-JOINTS. 557 injury. Any force from below, or acting on the back, may then produce dislocation downwards and forAvards, into the obturator foramen. Thus, a fall from a horse, with the thigh under the body of the animal, has had this effect; and Pirrie once found it caused by the person jumping in great haste out of bed, and while the left foot reached the floor, the right was entangled by the blankets in bed, thus separating the legs and thence producing dislocation into the obturator foramen. The fall of a heavy weight upon the back of the pelvis when the body is bent forwards and the thighs are apart, will also produce the dislocation. Fig. 197. FlG. 198< made upwards and outwards by a perineal girth connected with the pulleys; and counter-extension main- tained by another belt around the pelvis from the dislocated side. As the head of the bone is thus drawn towards its socket; the Surgeon passing his hand behind the sound limb, grasps the ankle of the dislocated limb, and drawing it inwards and backwards towards the middle line thus throws the head of the bone outwards and upwards to the aceta- bulum. The limb is here used as a long lever, over the resisting perineal girth, as a fulcrum. (Fig. 198.) This is Sir A. Cooper's method of reduction. Other methods have been devised, but they do not corre- spond more nearly to the direction of the displacement. In the absence of pulleys, however, it is well to have other resources, as follow:— (2) Let the patient sit upon the front of the bed, astride one of the bed-posts, and grasp it; while extension of the limb is made by two 558 SPECIAL PATHOLOGY AND SURGERY. assistants. Then, the Surgeon crossing the limb over the sound one, and rotating it outwards, may thus succeed in reducing the dislocation. This method was proposed and practised^ with success by Mr. Hey, of Leeds, in one case. (3) Manipulation seems to have succeeded in another case. Mr. Hey flexed the thigh to such an extent as to form an acute angle with the trunk, and then by rotating it, accomplished reduction. Dislocation Upwards and Forwards upon the Pubes.—Structural Condition.—The head of the femur rests on the anterior margin of the horizontal ramus of the pubic bone, with the great trochanter directed backwards. (Fig. 199.) Sometimes, the ball is driven up so high as to be hooked into the pelvis. The capsular and round ligaments are ruptured. In a case, dissected by Sir A. Cooper, Poupart's ligament was torn, so as to allow the head and neck of the bone to pass underneath the iliacus internus and psoas muscles; the anterior crural nerve lying upon these muscles and stretched over the neck. The femoral vessels were to the inner side. Fig. 199. Fig. 200. Signs.—The limb is shortened, gene- rally to the extent of an inch; flexed slightly, decidedly abducted, and everted. (Fig. 200.) The globular head of the femur can be plainly felt on the pubic bone, to the outside of the femoral vessels, and made to roll under the fingers by rotating the limb ; while the pro- minence of the great trochanter has disappeared, this portion of the bone being drawn inwards and upwards towards the anterior superior spinous process of the ilium. Immobility of the limb is a marked symptom, as regards rotation inwards; and powerlessness equally so, with pain or numbness frequently, owing to pressure on the anterior crural nerve. UNREDUCED DISLOCATIONS OF THE HIP. 559 The diagnosis from fracture of the neck of the femur, may be deter- mined ; by the situation of the head of the bone and immobility, with crepitus in the case of fracture; or if the fracture be impacted, the head of the bone is still diagnostic. Causes.—When the limb is directed backwards, and perhaps, ab- ducted ; dislocation upon the pubes may occur. Either, by a fall on the foot, as when a person slides down from the end of a waggon; or when walking, the foot is suddenly planted into a hole, the pelvis advances, while the upper part of the body is thrown forcibly backwards, in order to avoid a fall. A severe blow on the back of the pelvis may have the same effect in producing dislocation upon the pubic bone. Unreduced dislocation leads to the formation of a tolerably complete new joint. This result was found in the case examined by Sir A. Cooper. Upon the pubes a socket was formed for the neck of the femur, the head being above the level of the pubes. Both the latter portions of bone were flattened; the trochanter also was much altered in shape, and it partly occupied the acetabulum, which was otherwise filled with osseous deposit. This specimen is still in the Museum of St. Thomas's Hospital. Treatment.—The patient lying on his back, with the dislocated side near the edge of the bed; Extension should be made from the loAver part of the thigh, downwards and backwards, the pulleys being fixed accord- ingly 5 while counter-extension, by means of a perineal girth, is made in the opposite direction, over the body of the patient. (Fig. 201.) This Fig. 201. force having, as usual, been applied slowly, gradually increased, and steadily maintained; the head of the bone is lifted over the brim of the acetabulum, by a towel under the upper part of the thigh, and the ball directed backwards, by rotating the thigh inwards. " Anomalous" Dislocations of the Hip, in the various modified direc- tions already enumerated, occur too rarely to admit of any precise descrip- tion. The signs resemble in various degrees, those of the principal dis- locations ; and the treatment—by extension and counter-extension—must be modified according to the particular direction of dislocation. Unreduced Dislocations of the Hip.—Two months was the period fixed by Sir A. Cooper, as the extreme period within which such dislo- cations can, or should, be reduced. Increasing in difficulty and danger, as the operation of reduction may be up to that time; it subsequently be- comes extremely uncertain of accomplishment, and always perilous, owing to the liability of fracture or of abscess, from the straining injury to the soft textures. The former accident has occurred in the hands of some of the most able Surgeons; fracture taking place usually in the neck 560 SPECIAL PATHOLOGY AND SURGERY. of the femur or not far below the trochanters. Exceptional cases of successful reduction after a much longer period have more recently been recorded. Thus, two cases are cited by Hamilton, both cf six months standing, and it may be added, both dislocations on the dorsum ilii. The physiological consideration which, as a rule, should here, as in regard to all Dislocations, guide the Surgeon, is, the degree of efficiency of the new joint; as indicating the practicability and safety of attempting reduction, and its utility when accomplished. Dislocation of the Hip, with Fracture of the Femur.—This complica- tion is undoubtedly possible, but exceedingly rare. Reduction of the dislocation is said by Hamilton to be still more rare. The rule of practice, however, should always be to attempt reduction at the time of the acci- dent. This may be accomplished, under the influence of chloroform, simply by pressure on the head of the bone and with the requisite manipulation; or, by first setting the fracture and securing it Avith lateral splints, in order to make use of the limb for extension in reducing the dislocation. Failing at the time of dislocation to effect reduction, union of the fracture must be allowed to take place, and then it should be again attempted. This resource proved successful in one case, a dislocation on the dorsum ilii, of five weeks' duration; Mr. Badley being the operator. In another case, a dislocation into the sciatic notch ; reduction at the end of six weeks, as reported by Mr. Thornhill, appears to have been doubtful. It would seem that, probably, he re-fractured the bone; for the head of the femur is said to have resumed its place with a loud crash. Double Dislocation—i.e., of both hips, has been known to occur ; and in different directions on the two sides, or with fracture of one femur. Congenital Dislocations of the Hip-joint have been met with, complete or incomplete. The former correspond very nearly in their directions Avith the regular dislocations of the hip, and Avith one of the anomalous varieties—upward dislocation, in which the head of the femur is placed outside the anterior inferior spinous process of the ilium. These disloca- tions seem to occur much oftener in females than in males; and usually, they are single. Dislocations of the Patella are liable to occur in four directions; (1) outwards more commonly, or (2) inwards; (3) ver- tically, the patella turning edgewise on its axis ; or lastly, (4) upwards. Both the latter forms of disloca- tion are very rare. (1 and 2) Dislocation laterally, outwards, or in- wards. The structural conditions in these two forms of Dislocation are analogous; the patella is displaced more or less com- pletely, in either direction, and rests on the outer side of the external condyle (Fig. 202), or the inner side of the internal condyle (Fig. 203), of the femur. Fig. 202. Fig DISLOCATIONS OF THE PATELLA. 561 Signs.—An unnatural swelling—the projection of the patella, can be seen and felt over the outer or inner condyle; with an unnatural depres- sion in front of the knee, owing to the absence of the bone from its proper situation. The knee is much broader than usual, slightly bent, and im- movable ; considerable pain also is experienced, especially aggravated by any attempt to bend the joint. Causes.—Muscular contraction of the quadriceps extensor would seem to be the usual cause of these dislocations. The outward displacement is particularly liable to occur in persons Avho are knock-kneed, or Avhose external condyles have not the usual degree of prominence anteriorly. Dislocation of the patella in this direction may sometimes be produced voluntarily. A dancing girl, who, from her earliest years, had habitually twisted herself into various attitudes, eventually became knock-kneed; and when the rectus muscle acted upon the patella, it Avas thrown nearly flat upon the side of the external condyle of the femur. Sir A. Cooper— who relates this case—also found the dislocation reproduced in another instance whenever the limb was extended, displacement arising from dis- tension of the joint with synovial fluid. Indirect violence is sometimes the cause ; as a sudden twist of the thigh inwards, while the weight of the body resting on the foot, keeps the leg turned outAvards; or a fall Avith the knee turned inwards, and the foot outAArards. Direct violence, as a blow upon the inner or outer margin of the patella, may sometimes pro- duce dislocation outwards or inwards, respectively. These dislocations are very prone to recur. Treatment.—Reduction is easily effected. The patient lying on his back, the Surgeon raises the thigh towards the abdomen, so as to relax the quadriceps extensor muscle ; and then by pressing the patella inwards, or outwards, over the condyle, it is at once drawn into place by the action of that muscle. (3) In vertical dislocation, the patella turns on its axis and presents edgewise. One margin looks forwards, the other rests and is fixed, in the groove between the condyles. This twist may be more or less complete; Avhereby the margin of the bone looks obliquely forwards, or turns almost completely round so that the posterior surface of the bone partly becomes anterior. The latter displacement is very rare ; and indeed, any vertical dislocation is uncommon, not more than fifteen examples having been recorded. Signs.—Vertical dislocation presents very characteristic appearances ; the sharp projecting border of the patella can be clearly felt and seen under the skin; and the leg is forcibly extended, or sometimes flexed slightly. The same causes may turn the bone vertically on its axis, which displace it laterally; and—as Hamilton states—an incomplete lateral may be converted into a vertical dislocation, if the bone hitches on one margin, and the extensor muscle contracts suddenly and violently, thus raising the other margin, or even completely turning the bone on itself. Treatment.—Reduction can sometimes be accomplished Avith tolerable facility, or it may be extremely difficult, and sometimes impracticable, the margin of the patella being, it Avould appear, mechanically fixed in the intercondyloid fossa. The same method of reduction is applicable as for lateral dislocation; relaxation of the muscles by raising the thigh, and pressure on the patella, laterally on both margins, but in opposite direc- tions. Or, forcible flexion of the knee, Avith rotation of the tibia on the o o 562 SPECIAL PATHOLOGY AND SURGERY. femur, may succeed; forcible flexion and extension alternately, has also proved successful, or a violent effort by the patient to make these move- ments. This failing, subcutaneous section of the tendon of the quadriceps and of the ligamentum patellae, has been resorted to. But, in a case related by Mr. B. Cooper, from " Rust's Magazine," in his edition of Sir A. Cooper's work, this proceeding was more than unsuccessful ; reduction was still impossible, and extensive suppuration followed, under Avhich the patient sank and died. (4) Displacement upwards can only result from relaxation, or rupture, of the ligamentum patellae; thus permitting the patella to glide upwards in front of the femur. I have seen this occur once, from forcible flexion of an anchylosed knee-joint. The Signs of such displacement are sufficiently obvious. The patella is drawn upwards, an interval appears below it, or a fold inwards when the leg is placed in an extended position; there is also marked mobility of the leg and proportionate loss of extensor power, the leg hanging down nearly useless and swinging to and fro like a pendulum. The Treatment is the same as for fractured patella, or rupture of the quadriceps tendon. In the case referred to, the power of extension was but partially recovered. Dislocations of the Knee.—This joint is seldom dislocated ; neverthe- less, the head of the tibia is liable to undergo dislocation in four principal directions, and in the following order of relative frequency: (1) inwards, (2) outwards, (3) forwards, (4) backwards. The fir^t two dislocations are always incomplete; the latter two may be incomplete or complete. Velpeau has found on record 13 examples of complete dislocation forwards, and 8 backwards. Structural conditions. —(1) Dislocation of the head of the tibia laterally, inwards (Fig. 204); the external condyle of the tibia rests upon the internal condyle of the femur, and the lateral ligaments are more or less completely ruptured. (2) Dislocation laterally, outwards (Fig. 205); the internal condyle of the tibia rests upon the external condyle of the femur, and the lateral liga- ments are more or less entirely ruptured. (3) Dislocation of the head of the tibia, for- wards ; the head is situated partially, or entirely, in front of the condyles of the femur, according as the dislocation is incomplete, or complete. The condyles of the femur project, proportionately, backwards in the popliteal space. (Fig. 206.) (4) Dislocation of the head of the tibia, backwards; the head is situated partly upon the posterior half of the condyles of the femur, or it passes up and rests against the posterior aspect of their articulating sur- Fig. 204. Fig. 205. DISLOCATIONS OF THE KNEE-JOINT. 563 Fig. 206. Fig. 207. faces, according as the dislocation is incomplete or complete. The condyles of the femur project, proportionately, forwards. (Fig. 207.) In both the latter dislocations, (3) and (4), it is probable that the ligaments and sur- rounding structures are similarly injured. Thus, in backward dislocation, the posterior ligament of the joint is torn, the muscles of the ham are stretched, and the pop- liteal vessels and nerves compressed. With com- plete dislocation, the crucial or inter-arti- cular ligaments are also torn. Signs.—(1) Disloca- tion laterally, inwards or outwards, presents oppo- site appearances. In the one, an unnatural swelling, the inner condyle of the tibia, on the inner aspect of the knee; and another swelling—the external condyle of the femur, on its outer aspect. In the other dislocation or outwards, an unnatural swelling, the outer condyle of the tibia and head of the fibula, is found on the outer aspect of the knee ; and another swelling—the internal condyle of the femur, on its inner aspect. In both forms of dislocation, the leg is slightly flexed, or sometimes extended, and tAvisted, inwards or outwards, towards the side of dislocation, but not shortened. Immobility, with inability to use the leg and severe pain, are present, as more or less, in all dislocations. All these signs or symptoms were marked in two lateral dislocations; one of which occurred in my Hospital practice; the other, an outward dislocation, in the case of a lady, avcII known to me, but who, at the time of the accident, many years since, Avas under the able care of Mr. Pitt, of Norwich. This case is recorded in the "American Journal of Medical Sciences," vol. xxxi.; and it is also noticed in Hamilton's work. Mr. Pitt's patient quite regained the use of her leg: similar dislocation again occurred about a year afterAvards, and Avas reduced in the act of carrying the patient up-stairs, by her foot acci- dentally getting entangled in the bannister-rails; it happened again about three months subsequently, when the knee jerked into place spon- taneously ; and I am happy to say, that excepting a slight Aveakness of the knee, she now suffers no incom'-enience. (2) Dislocation forwards or backwards, also presents opposite appear- ances. In the one, a large swelling, the bulky head of the tibia, pro- jecting in front of the knee, Avith a deep depression immediately above it and the patella; and another large SAvelling—the condyles of the femur, in the popliteal region. In the backAvard dislocation, a large swelling, the bulky head of the tibia, can be felt in the popliteal space; and another large swelling—the condyles of the femur, in front of the knee, Avith a deep depression beloAV in the situation of the ligamentum patellae. In both these forms of dislocation, the leg is flexed ; in the one case, o o 2 564 SPECIAL PATHOLOGY AND SURGERY. slightly back upon the thigh; in the other, extended or bent unnaturally forwards from the line of axis of the femur; shortening also is con- spicuous, if either dislocation be complete, and varying in extent from one to two inches, or more. Severe pain, and swelling of the limb, may arise from compression of the popliteal nerves and vessels. Causes.—All these dislocations of the knee usually arise in like manner. Indirect violence is, perhaps, the most frequent cause; as when the foot is made fast in a hole, and the tibia twisted upon the femur either by the body swinging around upon the knee; or by a fall from some height, or by the individual jumping from a carriage in motion. Direct violence, is represented by a blow upon the upper end of the tibia, or upon the lower end of the femur. In one remarkable case, recurring dislocation backwards Avas produced, as it seemed to me, by hydrops articuli. The head of the tibia passed backwards whenever the patient, a Avoman, bore any Aveight on her foot and attempted to walk. Similar dislocation, or a tendency thereto, is not an uncommon result of disease of the knee- joint, with retraction of the leg, causing the end of the femur to project forwards in standing or walking. Unreduced dislocation of the worst form, or backAvards, may termi- nate in the recovery of a tolerably useful limb. Three such incomplete dislocations, backAvards and unreduced, have been seen by Malgaigne, and neither of the persons thus affected were very greatly maimed in consequence, One walked with crutches after three or four days, and with a cane after about five weeks. Another did not leave his bed under one month, and it was nearly one year before he could lay aside his crutches; but both of these individuals were finally able to walk at least twelve leagues a day. In a similar case seen by Lassus, the patient was confined to bed two years, yet he finally recovered a tolerable use of his limb. Reduction, promptly effected, with sufficient rest of the limb, is followed by sound recovery or very little if any maiming, ultimately. This issue may be hopefully anticipated even when dislocation has oc- curred repeatedly at distant intervals, as happened in Mr. Pitt's case. Treatment.—Reduction can be accomplished, in the same way, in each form of dislocation of the knee. Flexing the thigh towards the abdomen, and fixing it for counter-extension, extension is then applied to the leg, in the direction of the long axis of the displaced tibia; pres- sure being made, at the same time, on the ends of the bones in opposite directions, so as to overcome the displacement. Thus, pressure should be applied laterally, on the head of the tibia in particular, inwards or outwards, according to these forms of dislocation; and on the same bone, dowmvards and backwards, in forward dislocation; or downwards and forwards, in backward dislocation. Splints should be employed to fix the joint, and the appropriate measures also for subduing inflammatory swelling which is often considerable. At the end of two, three, or four weeks, according to circumstances, passive motion may be used gently at intervals, and the joint allowed gradually to resume its functions. Internal Derangement of the Knee-joint—so named by Hey, who first described it—or subluxation of the knee, sometimes so called. This accident is not uncommon. The structural condition is, probably, a partial dislodgment of one of the semilunar cartilages, owing to a disruption of its ligamentous con- nexion with the margin of the condyle; the thick margin of the carti- lage thus becoming interposed between the articulating surfaces of the DISLOCATIONS OF THE KNEE-JOINT. 565 opposed condyles of the femur and tibia ; or part of the cartilage slipping before or behind the condyle, the articulatory surfaces are brought into contact. An analogous condition, in relation to the symptoms thence arising, may also occur; by the interposition, either of a fragment of one of the cartilages, or of an hypertrophied portion of cartilage, or of a false cartilage—a new formation, moving about more or less freely within the joint. Symptoms and Causes.—Sudden inability to use the joint, is felt, which becomes locked, while Avalking, or by striking the toe against something, or by tripping the foot. Intense and nauseating pain accompanies this sudden locking of the joint, and the person falls to the ground. Any slight twist of the leg, as in bed, by the mere Aveight of the bedclothes hanging upon the toes, has been known to produce the same effect. In either case, the joint is slightly flexed, and the leg perhaps somewhat rotated. Considerable swelling of the knee rapidly supervenes, and the synovial capsule becomes distended with fluid ; in short, subacute synovitis ensues from this injury. It is very likely to recur, again and again; thus rendering the prog- nosis unfavourable. Treatment.—This " internal derangement" disappears, in most cases, as easily as it was produced. Flexion, with sudden extension, and slight rotation of the leg, will generally overcome the difficulty, if indeed it should not suddenly right itself. Immediately, the motions of the joint become free and painless, so that the individual can walk about as if nothing had happened. But it is better to place the joint at rest for a while, subdue any synovitis which may have supervened, and then support the knee for some time by means of a knee-cap, to guard against the liability of recurrence. Compound Dislocation of the Knee-joint.— Fig. 208. This injury must be regarded as the most perilous of its kind, but fortunately it is of rare occurrence. (Fig. 208.) Treatment.—An attempt to preserve the limb Avill scarcely ever prove successful; and, excepting in a few cases of more limited damage to the popliteal vessels, nerves, and the integuments, Avhere excision may be sufficient, amputation is the only resource. The injunction originally given by Sir A. Cooper to sacrifice the limb, Avill generally be unavoidable for the probable preservation of life. Congenital Dislocations of the Knee.—The head of the tibia has been found, at birth, dis- located in various directions; forwards, back- wards, inwards, outwards, inwards and back- Avards, outwards and backwards, and simply rotated imvards. The first-named dislocation is much the most frequent; and the majority of all these congenital dislocations were incomplete. Double dislocations have been found in some instances. Thus, both tibiae were displaced back- Avards in an infant otherwise deformed, according to Chaussier's observations. 566 SPECIAL PATHOLOGY AND SURGERY. Dislocations of the head of the Fibula.—The upper end of the fibula may, occasionally, be dislocated forwards or backwards. Of the former dislocation, Malgaigne has collected three examples, unconnected with any other accident, and not apparently due to any abnormal condi- tion of the ligaments. I have seen another, or fourth, such dislocation, which had remained unreduced. Of backward dislocation, Hamilton enumerates three cases on record. The Signs of these dislocations are very palpable; the projecting head of the bone, immediately under the skin, forwards or backwards, cannot fail to be observed. The Cause is almost necessarily direct violence, as a blow on the head of the fibula. But muscular action is said to have produced two, at least, of the three forward dislocations. The consequence of any such dislocation may be a laxity of the joint, with mobility of the fibula backwards and forwards upon the tibia. This was the result in one of the backward dislocations recorded by Sanson. Treatment.—Reduction having been effected by pressure, the head of the bone must be kept in place by a compress and bandage. Dislocation of the Lower end of the Fibula.—The only instance of simple dislocation is related by Nelaton as having occurred in the practice of M. Gerdy. It was a backward dislocation, of thirty-nine days' duration, and caused by the wheel of a carriage passing obliquely across the leg so as to displace the outer malleolus, backwards. The bone was in almost direct contact with the outer margin of the tendo- Achillis, the outer face of the astragalus, abandoned by the fibula, could be plainly felt, and the position of the foot remained unaltered. The patient could walk pretty well, the bone was fixed, and reduction not attempted. Dislocations of the Ankle-joint.—The astragalus in connexion with the foot may be dislocated from the articular ends of the tibia and fibula, in four directions; (1) outwards, (2) inwards, (3) forwards, and (4) backwards. They may be termed dislocations of the foot in these directions. Most of these displacements are accompanied with fracture of the fibula, the tibia, or of both bones. The description of these several forms of dislocation will, I think, be simplified by re- garding them, conversely, as relat- ing to the tibia. Structural Conditions.—(^Dis- location outwards. The lower end of the tibia is displaced laterally inwards upon the astragalus (Fig. 209); the outer portion of the articulating surface of the tibia resting upon the inner portion of the upper articulating surface of the astragalus, or it may slide com- DISLOCATIONS OF THE ANKLE-JOINT. 567 pletely off in the same direction. The foot is turned outwards—everted. The internal lateral ligament is ruptured, or the inner malleolus may be broken, or both ; the fibula, also, usually gives way two or three inches above its articulation with the astragalus. (Fig. 210.) Sometimes, in addition to these injuries, there is an oblique fracture of the tibia upwards and outwards from the articulating surface, breaking off that portion of the tibia which corresponds to the inferior tibio-fibular articulation; this fragment remaining connected with the outer malleolus, while the tibia carries inward Avith it the portion of the fibula above the fracture. Fig. 210. Fig. 211. Fig. 212. (2) Dislocation inwards.—The lower end of the tibia, and of the fibula, are displaced laterally outwards; and, perhaps, completely, the articulating surface of" the tibia entirely sliding off the upper surface of the astragalus. (Fig. 211.) The inner malleolus is broken off the tibia, but remains attached to the tarsus by the internal lateral liga- ment ; and the external lateral ligament is ruptured, or the outer malleolus may be broken off the fibula, thus making a fracture of both malleoli. The foot is turned inwards—inverted. (3) Dislocation backwards.—The lower end of the tibia is displaced forwards on the astragalus, resting partly on this bone and partly on the scaphoid bone; or com- pletely forward, the tibia then resting on the scaphoid and internal cuneiform bones. (Fig. 212.) The foot in front of the ankle, is shortened. In the latter or complete dis- placement, especially, the lateral ligaments are more or less completely ruptured; generally, the fibula is fractured but on a level Avith the articulation; sometimes, the internal malleolus also, and still more rarely, a fracture occurs through the posterior mar- gin of the articular surface of the tibia. (4) Dislocation fonvards.—This injury happens even more rarely than the pre- ceding, but Malgaigne has collected five instances. The lower end of the tibia is displaced backwards on the astragalus, resting partly on 568 SPECIAL PATHOLOGY AND SURGERY. this bone and partly on the os calcis, behind it. (Fig. 213.) The foot in front of the ankle, is elongated. Dr. R. W. Smith believes that this dislocation is never complete, so that the tibia shall lodge entirely on the os calcis. The lateral ligaments are rup- tured, or one or both malleoli are broken. Signs.—Dislocation laterally outwards or inwards, presents op- posite appearances. Outward dis- location is characterized by vio- lent eversion of the foot, its inner margin being directed down- wards ; the inner malleolus pro- jects prominently under the in- teguments, and there is a corre- sponding depression above the outer malleolus, in the situation of fracture of the fibula. Crepitus may here be detected, and the foot can be moved about pretty freely by the Surgeon, but with great pain. Inward dislocation is distinguished by inversion of the foot, its outer margin looking downwards; and the outer malleolus projects strongly under the skin. Dislocation backwards and forwards, also present opposite appearances. Backward dislocation is attended with shortening of the foot in front of the tibia, and depression of the toes; while the heel is elongated, pro- jecting posteriorly, and drawn upwards. The extensor tendons of the toes are sharply defined, and the tendo-Achillis is curved tensely forward. The foot is immovable. These signs are even more marked with complete dislocation ; the end of the tibia can be distinctly felt projecting forwards, accompanied with an evident depression posteriorly in front of the tendo- Achillis. Forward dislocation is characterized by lengthening of the foot in front of the tibia, and elevation of the toes; with corresponding oblite- ration of the heel, which is in a line with the back of the leg, and depressed downwards. A portion of the articulating surface of the astragalus may be felt in front of the tibia. Causes.—Direct violence ; as a severe twist or wrench of the foot out- wards or inwards, represents the ordinary mode of producing either lateral dislocation; the displacement taking place, obviously, in the opposite direction to such force. Indirect violence ; as a fall from a height upon the bottom of the foot may have a similar effect; if the foot have a suf- ficient inclination to either side, to thus direct the force of the impulse in favour of dislocation to that side. Forcible flexion or extension, may produce dislocation backwards or forwards, respectively. A fall on the bottom of the foot, the body inclining backwards or forAvards, tends also to produce dislocation in the opposite direction. But a person jumping out of a carriage in rapid motion and alighting on his feet, is liable to dis- location in the direction of the momentum. Thus, from jumping out for- wards, the dislocation will be forwards ; from jumping out backwards, the dislocation will, probably, be backwards. Treatment.—All these dislocations are reduced in like manner. The leg should be flexed to a right angle on the thigh, to relax the conjoined gastrocnemius and soleus muscles; extension is then made from the foot in a line with the long axis of the leg, taking care that the foot inclines midway between flexion and extension of the ankle-joint, and by drawing DISLOCATIONS OF THE ASTRAGALUS. 569 with one hand on the back of the foot and the other hand on the heel. Pressure on the end of the tibia, according to the direction of the dis- placement, Avill further aid reduction. Lateral splints with foot-pieces may then be applied ; but I prefer a Mclntyre's trough splint, as affording a more equable support to the whole leg. The SAvelling around the joint is often considerable; it, hoAvever, subsides under the influence of rest and the usual topical applications. Compound Dislocations of the Ankle-joint, are probably the most common of all compound Dislocations. Among the cases recorded by Sir A. Cooper, 45 were dislo- cations of this joint; and among Hamilton's cases, 4 were dislocations inwards, and 1 a partial dislocation forwards. The displace- ments are the same, and arise from the same causes, as in simple dislocation of the ankle; but compound dislocation derives its im- portance from the size of this joint, and the violence of the injury. (Fig. 214.) Treatment.—Preservation of the foot—without any operative inter- ference—proves successful in a far larger proportion of cases than in similar injury of the knee-joint. The Avound should be closed and the leg kept at rest on a Mclntyre's splint. Protrusion of the tibia with comminution, as often happens in backAvard dislocation, allows of excision, in most cases. But severe contusion or laceration of the soft parts, in- cluding injury to the tibial arteries—in addition to compound dislocation of the joint—imperatively demands primary amputation. The usual con- sequences of inflammation, suppuration and sloughing, or gangrene, may render secondary amputation necessary, Avhen an attempt to save the foot has failed. Dislocations of the Astragalus.—This bone is sometimes displaced from under the tibia, and throAvn—(1) forwards, (2) outwards, or (3) inwards ; the two latter displacements probably being inclinations of the bone forwards in either of these directions, thus constituting two lateral dislocations; and occasionally it may be displaced (4) backwards. It may also—observes Hamilton—be simply rotated on its lateral axis, Avithout much, if any, lateral displacement; and lastly, it is, sometimes, driven upwards betAveen the tibia and fibula, tearing away the intermediate ligaments and generally fracturing one or both these bones. (1. 2. 3) Dislocation forwards, and outwards, or inwards; may be complete or incomplete. Complete dislocation of the astragalus represents its detachment from the os calcis and scaphoid bones, and its displacement from under the malleolar arch forwards ; the bone lying upon the scaphoid and cuneiform bones. Incomplete dislocation signifies the separation of this bone from the scaphoid only, and the ejection of its head on to the external cuneiform or cuboid bones ; the body of the astragalus still retaining its connexion Avith the os calcis, and malleolar arch. (4) Dislocation backwards is a dislodgment of the astragalus on to the os calcis behind the tibia, in the interval between it and the tendo-Achillis. 570 SPECIAL PATHOLOGY AND SURGERY. Signs.—The projection of the astragalus Avhich can be felt and seen, in each of these directions of dislocation, is alone sufficient to indicate the nature of the injury. (Fig. 215.) The malleoli are nearer the sole of the foot, the tibia having fallen down upon Fig. 215. the os calcis; and there may be some flexion or extension of the foot. The Causes of astragaloid dislocation re- semble those of ankle-joint dislocation. Thus, a fall from a height upon the bottom of the foot, accompanied with violent abduction, ad- duction, flexion or extension, may determine a dislocation of the astragalus—forwards, in- wards, outwards, or backwards; a wrench or twist of the foot, in machinery or in the wheel of a carriage, for example, is another mode of production. A direct blow may also be the cause. Unreduced dislocation of the astragalus is a not uncommon result, reduction being often very difficult and having proved impos- sible. Recovery of the use of the foot has been attained so far as to enable the person to walk again, but with considerable crippling. Reduction, on the other hand, even when promptly and easily effected, has been fol- lowed by inflammation and gangrene, resulting in death. Treatment.—Reduction—when practicable—can be accomplished in the same manner as in dislocations of the ankle. Flexion of the leg to a right angle with the thigh, relaxes the muscles of the calf; and then ex- tension from the foot, with counter-extension from the lower part of the thigh, aided by pressure on the displaced bone, will perhaps replace it. Division of the tendo-Achillis is said to have facilitated reduction in obstinate cases. The probability of effecting reduction depends very much on the dis- location being incomplete; complete dislodgment of the bone will be very difficult to overcome. The tibia and os calcis, powerfully drawn together, can hardly be separated to an extent sufficient for the return of the bulky astragalus; itself also bound down by the extensor tendons, in forward dislocation, and by the tendo-Achillis in backward dislocation. Should reduction haAre proved impossible, the integument over the projecting astragalus, will probably slough and expose the bone ; antici- pating this result it is better forthwith to proceed to excision, even if the dislocation be simple. Compound Dislocation presents no peculiarity otherwise than the more serious nature of the injury, from exposure of the bone, and as oc- casioned by more severe violence. (Fig. 216.) Excision, or amputation, are the only alternatives. Dislocations of the other Tarsal Bones.—Such dislocations are very rare. The Calcaneum may, however, be dislocated outwards from the astragalus alone ; or from the cuboid bone simultaneously, in a direction outwards and upwards. It has also been found dislocated outwards from the astragalus and inwards upon the cuboid bone. DISLOCATIONS OF THE OTHER TARSAL BONES. 571 The deformity is sufficiently characteristic. These dislocations have arisen from a fall on the heel. Fig. 216. The Scaphoid and Cuboid bones, together, may be dislocated from the astragalus and calcaneum, upwards — the middle tarsal dislocation of Malgaigne. The foot is shortened, and the instep raised ; presenting the deformity of club-foot. This injury also has arisen from a fall, but on the ball of the foot. The cuboid bone alone may, it is said, be dislocated upwards, inwards, and downwards; but Malgaigne has found no case recorded of this dis- location alone, unaccompanied with that of one or more of the other tarsal bones. The scaphoid bone alone has been found dislocated from the cuneiform bones, its connexion with the astragalus remaining undisturbed. The dislocation was compound, yet—after reduction—the wound healed rapidly, and recovery soon became established. Dislocation of the scaphoid from both the astragalus and cuneiform bones, has occurred in several instances. The Cuneiform bones may be partially dislocated, and without having separated from each other; of which two or three examples are recorded. The internal cuneiform bone alone, has been dislocated inwards. Sir A. Cooper saw two instances, in both of which the same appearances were presented ; great projection of the bone inwards, with some elevation by the action of the tibialis anticus muscle, and the bone no longer remained in a line Avith the metatarsal bone of the great toe. A fall from a height produced this dislocation in the one case; and in the other, a fall from a horse, the foot being caught between the horse and the curb-stone. In neither case was the bone reduced; but the subject of the first of these accidents walked Avith only a little halting. The Treatment of all these dislocations of the Tarsal Bones is the same. Reduction may, possibly, be effected by pressure on the displaced bone. A compress and foot-splint, will then be required to allow the bone to regain its ligamentous connexions. Dislocation of the Metatarsal bones—is, also, very rare. The metatarsal bone of the great toe has been dislocated upwards, an instance of Avhich from direct violence Avas seen by Liston, and reduced. The inner three metatarsal bones Avere dislocated downwards and backwards, in a case recorded by Tufnell, and as resulting from a fall upon the leg 572 SPECIAL PATHOLOGY AND SURGERY. by a horse rolling on its rider; Erichsen also found the outer three meta- tarsal bones dislocated downwards, by the pressure of a " turn-table " on a railway. The causes are usually a fall backwards or forwards, the anterior extremity of the foot being wedged under some resisting body. Various crushing accidents also sometimes occasion these dislocations. The treatment must be conducted on ordinary principles. Dislocations of the Phalangeal bones of the toes, resemble those of the Fingers, and do not require a separate notice. In a case—related by Sir A. Cooper—all the smaller toes were dislocated forwards; a projection existed at their roots, and the extremity of the metatarsal bones bulged under the first phalanx of the corresponding toes. This displacement had been caused by a fall, from a considerable height, upon the extremi- ties of the toes. Several months had elapsed, and reduction could not be effected. Walking was rendered more tolerable by wearing a piece of hollow cork at the bottom of the inner part of the shoe, to prevent the pressure of the metatarsal bones upon the nerves and blood-vessels. Congenital Dislocations of the Bones of the Foot.—These Injuries are associated Avith the various forms of Talipes or Club-foot. CHAPTER XXXIV. DISEASES OF JOINTS. Unlike Diseases of Bone—wherein the osseous texture or bone proper, the periosteum, and the medullary membrane or endosteum, are less separately and distinctly the seat of any particular morbid condition ; Diseases of joints relate to the synovial membrane, the articular ends of bone, and the articular cartilages, not to mention the ligaments, as, seve- rally, the seats of disease ; although any such morbid condition, isolated primarily, often spreads to the adjoining structures, secondarily. Thus, the component structures of the joints have each an individuality in rela- tion to Disease ; and Diseases of the joints have reference essentially to these component structures. This pathologically analytical view of joint-diseases—with regard to their seat and origin in joint-structures, is due to Sir B. Brodie ; prior to whose observations, both clinical and pathological, Diseases of the joints were confounded under the ambiguous terms, " Arthritis," and " White SAvelling." Synovitis.—Inflammation of the Synovial Membrane.—Structural Condition. — An inflamed synovial membrane is more vascular than natural, in the form of crimson spots or diffused redness, and loses its glistening appearance. The synovial secretion is increased in quantity, and thinner. These are the earliest changes. As inflammation proceeds the membrane acquires a pulpy thickening and opacity, by interstitial exudation, and lymph is effused from its inner surface, giving it a gra- nular or villous appearance, and forming flakes in the synovial fluid which also accumulates in quantity. Some effusion may even occur in the sub- serous cellular tissue. This represents the adhesive stage of synovitis • an event, however, which rarely supervenes, as the opposed surfaces of the SYNOVITIS. 573 interior of the synovial Capsule become yet more separated by its in- creasing distension. Subsequently, pus may be secreted Avithin the capsule, which thus becomes converted into an abscess. Signs.—The knee-joint may be taken for example, in regard to Syno- vitis, as it is more commonly affected than any other joint. Coincident Avith the earliest stage of inflammation, pain is experienced by the patient, and usually referred to a particular spot, perhaps the inner edge of the patella; afterwards extending over the whole articulation. The pain has no specially distinctive character. It is severe in proportion to the depth of the articulation and the unyielding nature of the ligamentous and other surrounding structures. It is also most intense in synovitis of a rheumatic or gouty origin, and as if the joint Avere compressed by a vice, or being violently torn open. In a period varying from two or three hours to as many days, according to the intensity of the inflammation, swelling makes its appearance. The consistence and shape of this syno- vial swelling are characteristic. At first, fluid and fluctuating, it becomes semi-solid as lymph is effused, and again resumes its original fluidity in the event of suppuration. But the shape of this SAvelling is even more remarkable. Throughout the courseof synovitis, it corresponds to the shape of the synovial capsule ; presenting that outline more clearly according to the degree of distension, and as modified by the compression of surrounding ligaments and tendons. The swelling, therefore, varies in form with each articulation, and its relation to the ligaments and ten- dons. Thus, in the knee, the swelling of synovitis is most conspicuous as a protrusion on either side of the ligamentum patellae, betwixt it and the lateral ligaments, and rising up above the patella, bulges in a uniform shape as high as the distended capsule may extend. In the elbow, the swelling projects on the posterior aspect of the joint, above the olecranon, and under the extensor muscles of the forearm. In the ankle, it presents on each side, between the lateral ligaments and the anterior tendons. In other joints less superficial, as the shoulder and hip, the swelling of syno- vitis is less perceptible ; in the one being obscured by the cushion of the deltoid muscle ; in the other, however, an evident fulness of the groin and sometimes of the nates, can be detected. The Avrist-joint is far less frequently subject to synovitis; but here a general fulness and some bulg- ing between the tendons—extensors and flexors, shows a conformity to the rule of characteristic swelling. Heat, and, possibly, redness of the skin around the joint, will also be more or less evident; but these signs are not diagnostic. The attitude of the limb is more or less peculiar, or becomes so. The joint is placed in the position most easy to the patient, and usually becomes semi-flexed. Constitutional febrile disturbance, in some degree, accompanies these local symptoms. Causes.—Exposure to cold, or some occasion of injury, as a blow or fall, may give rise to synovitis. The disease thus occurs in joints Avhich are most superficial and exposed, as the knee and ankle. But these causes are usually backed by some predisposing constitutional condition; especially rheumatism, scrofula, constitutional syphilis, or formerly, by the poisonous administration of mercury. Several joints may then be affected simulta- neously. Inflammation of the synovial membranes also ensues, occasionally, from gonorrhoea or purulent ophthalmia. Such synovitis has been incor- rectly named "gonorrhceal rheumatism,"although not apparently depend- ing on a rheumatic condition. Gonorrhceal synovitis would be a more correct designation. Arising after gonorrhoea of a few Aveeks' duration, 574 SPECIAL PATHOLOGY AND SURGERY. it affects one or more joints. The gonorrhoeal discharge may subside, or continue concurrently. Serum rather than lymph is effused into the joint, and the disease terminates without disorganization, in a feAv Aveeks. Or, it proceeds, sometimes, to ulceration of the cartilages, and continues for months or a year or two. In one such case, under my care, the knee- joint became firmly anchylosed. Pyaemia induces a low inflammation of the joints, the special character of which is its abundant sero-purulent effusion, and consequent swelling ; unattended by pain, heat and redness, the ordinary symptoms of inflam- mation. Ulceration of the cartilages ensues if the patient lives long enough. Terminations.—(1) Resolution commonly occurs; the pain, SAvelling, and other symptoms subsiding, and the joint regaining apparently a healthy condition. (2) Adhesion, or complete fibrous anchylosis, some- times results; the fluid portion of the effusion being absorbed, the sur- faces of the synovial membrane come together and are partially united by fibrous adhesions; thus leaving the joint much stiffened, in the state of fibrous anchylosis. (3) Fluid remaining in the synovial capsule; the swelling becomes persistent, with laxity and weakness of the joint; con- stituting chronic synovitis. An extreme degree of this condition has been named hydrarthrosis or hydrops articuli,—dropsy of the joint. (4) Sup- puration and abscess having occurred; the articular cartilages undergo ulcerative disintegration, and the subjacent bone is liable to become carious—thus ending in total disorganization of the joint; or anchylosis supervenes—sometimes fibrous and stiffly moveable, sometimes bony and fixed. The head of the femur and acetabulum, for example, both de- nuded of cartilage, may be found to have undergone anchylosis—fibrous, or even osseous. Or, an articular abscess opens, attended with a tempo- rary relief of the symptoms; but a wasting discharge ensues, and the inflammatory fever is exchanged for hectic, under Avhich the patient would ultimately sink from exhaustion, unless the disorganized joint has been removed in time. Treatment.—Absolute rest of the joint should be observed, as prima- rily important; the limb being placed in that position Avhich is most easy to the patient, and most convenient in the event of any stiffness remaining. A somewhat flexed position will, generally, best answer this twofold pur- pose. The limb may be sufficiently steadied by laying it on a soft pillow, which thus partially envelopes the joint; or, a suitable splint should be applied to insure rest. Local depletion, by leeches followed by warm fomentations, or cold lotions or irrigation will be appropriate, according to the intensity of the inflammation. Constitutional treatment has refe- rence to the inflammatory fever, and any constitutional cause of the inflammation. Hence, saline antimonials with perhaps calomel and opium, may be sufficient to subdue the febrile disturbance and check effusion ; or the special treatment for rheumatism, constitutional syphilis, or other such causative condition, may be requisite. Gonorrhoeal synovitis is amenable to the same treatment as that arising from rheumatism. Thus, colchicum and iodide of potassium sometimes prove remedial. But the disease, in most cases, runs its course; or a change of climate from a cold and damp atmosphere to the southern coast, may be followed by a speedy subsidence of the symptoms. By this plan of treatment, synovitis, in an early stage, Avill probably terminate by resolution or slight effusion. CHRONIC RHEUMATIC SYNOVITIS. 575 Chronic, synovitis must be treated with a view to the removal of the accumulated effusion, and consequent weakness of the joint. Counter- irritation in the form of blisters should be employed to overcome any persistent inflammation ; followed by stimulating embrocations, and pres- sure to promote absorption. Two or three blisters in succession are certainly preferable to a single blister kept open with savine ointment. The discharge produced by savine ointment soon ceases, and the surface of the skin acquires a mammillated appearance from enlargement of its papillae. The blisters should not be applied directly over the inflamed joint, but in the neighbourhood. Thus, in the case of the knee, a blister applied on either side of the thigh just above the joint; and Avith regard to the hip, a blister may be placed on the groin or nates. Of stimulating embrocations, a liniment of turpentine and olive oil, or the iodine paint, are perhaps most efficacious. Pressure can be applied by means of a gutta-percha or pasteboard splint, moulded to the joint; or the joint may be strapped with soap-plaster spread upon leather. The emplastrum ammoniaci cum hydrargyro conveniently combines both stimulation and pressure. Injection of the joint with tincture of iodine has been much employed by Velpeau, Jobert, and Bonnet; and it is recommended with more reservation by Erichsen. The tincture is diluted Avith tAvo or three parts of water. A small trocar is introduced into the joint, a portion of the serous fluid let out, and a corresponding quantity of the iodine solu- tion throAvn in, and after being left for a few minutes, is allowed to escape. Inflammation thus produced has, it is said, in no case been followed by serious consequences, but frequently by a complete cure Avithout anchy- losis. In a case of hydrarthrosis of the knee, in an old man ; Mr. Erichsen dreAV off about six ounces of thin synovia, and injected a drachm of strong tincture of iodine into the joint. Only slight inflammation ensued, and the disease, of two years' duration, was completely cured. The precautions necessary are; a very chronic, passive, state of effusion, and that no air should enter the joint. Constitutional treatment, by the influence of iodide of potassium and cinchona bark, cascarilla, or other tonics, will aid these local measures. Suppuration and abscess, in the interior of a joint, should be met promptly, by evacuation of the matter. The presence of pus having been first assuredly ascertained by puncturing the joint with a grooved needle; an opening with a bistoury should be made forthwith, freely, and in a dependent situation. This proceeding was, I believe, originally advocated by Mr. Gay, and it has been sanctioned by subsequent experience. Per- fect rest of the joint must then be secured by splints, and the limb placed in the position most convenient for use, in the event of anchylosis. A suitable kind of anchylosis having been attained, fibrous or osseous, according to the use of the limb ; it will be unnecessary to have recourse to further operative interference, by excision or amputation. Constitu- tional treatment consists in the tonic medicinal resources and supporting regimen, requisite to sustain the exhaustion of hectic. Chronic Rheumatic Synovitis, or Chronic Rheumatic Arthritis.— Structural condition.—This inflammatory disease involves other joint- textures besides the synovial membrane; but that is the texture first affected. Sir B. Brodie, Cruveilhier, and Dr. R. Adams, alike concur in this view of the structural origin of the above named disease. Hence, the substantive term synovitis seems preferable to that of arthritis, proposed by Dr. Adams; the etymological signification of the latter term including 576 SPECIAL PATHOLOGY AND SURGERY. inflammation of any or all the structures of a joint (apQpov, a joint). That would appear also to be a revival of the old nomenclature, which Sir B. Brodie's pathological investigation, Avith reference to the earliest changes in the various "Diseases of the Joints," was specially designed to correct, and has so advantageously superseded. Chronic Rheumatic Synovitis differs only from ordinary Chronic Synovitis in certain particulars as to its pathology, and treatment, which are, however, worthy of separate notice. The inflammation of the synovial membrane seems to affect the vascular fringe-like processes of this mem- brane more particularly, which are much developed and injected ; the internal surface of the capsule presenting the appearance of a villous mucous membrane. Effusion of fluid within the joint, takes place to a moderate amount, and is eventually absorbed. But the membrane itself remains thickened and fibrous ; while osseous deposits frequently form, partly in its substance, principally around the joint, connected with the periosteum and articular ends of the bones. Hence the term nodosity of the joints, proposed by Dr. Haygarth, as expressing one of the most dis- tinctive features of chronic rheumatic synovitis or arthritis. The liga- ments become relaxed ; the articular cartilages undergo peculiar changes; becoming fibrous and having a yellowish hue, ultimately being destroyed, and presenting patches of ivory-like bony material or porcellanous deposit, white, smooth, and glistening. This acquires even a high polish under the attrition of the surfaces, and linear furrows are formed in the direc- tions of friction by the movements of the joint. Inter-articular ligaments and fibro-cartilages are more or less destroyed and disappear; thus the round ligament in the hip-joint, and the long head of the biceps in the shoulder-joint, are removed by absorption. The sub-cartilaginous osseous structure is much condensed, and the whole articular end of the bone enlarged and deformed by the surrounding osseous growths; while the articular surfaces become singularly altered in shape. Thus, the globular heads of the femur and humerus are flattened and expanded, and their necks shortened ; the corresponding articular cavities also being enlarged and shallow. These alterations with the bony buttresses thrown out around the articular ends, have sometimes been mistaken for fracture with bony union, in examining such pathological specimens of the neck of the femur or humerus. The Signs of chronic rheumatic synovitis or arthritis are distinctive ;— pain, enlargement and ultimate deformity of the joint, rigidity or stiffness, and a peculiar crackling noise on moving the joint. The pain is not acute, but of an aching character, worse at night, increased by motion, and aggravated by cold and moisture; it is, in short, rheumatic pain. The general health may remain comparatively unaffected. The Causes of this disease always have reference to the constitutional condition of Rheumatism, and sometimes, exposure to cold or injury as an exciting cause. Thus chronic rheumatic synovitis may result from rheumatic fever or from repeated attacks of rheumatism; or in a person predisposed, direct exposure of a joint to cold or some slight injury, as a sprain, may evoke the disease. Many joints are liable to be affected, the disease passing from joint to joint without relieving those originally attacked; or only one joint may be affected. The larger joints, especially the hip, seem to be most frequently attacked in males; the smaller joints, as those of the fingers, in females. But. apart from this relative difference, both sexes would seem to be nearly equally liable to the disease. Age SCROFULOUS SYNOVITIS. 577 has no special proclivity; the disease usually occurs after mid-life, but it may also appear in young persons. No social condition is exempt; the poorly fed and hard-AVorked being prone, the luxurious and indolent, subject to this disease; in the latter class, assuming the character of rheumatic gout. Course and Terminations.—Chronic rheumatic synovitis is singularly persistent, evincing little tendency to subsidence, or termination by reso- lution. The irregular enlargement and deformity of the joints, Avith the weakened state of the ligamentous structures, and altered shape of the articular surfaces, predispose to partial dislocations; leaving the patient stiffened and crippled in his movements, and ultimately reduce him to a helpless condition. Loose cartilages, moreover, are apt to form in the joints. Suppuration rarely, if ever, occurs ; the disease—apart from any temporary effusion of fluid—is essentially a dry disease of the joints. Anchylosis also is a rare event; although the increasing articular rigidity, and wasting of the diseased muscles, have an equivalent result. Treatment.—Preventive measures, in the early stage of this disease, may succeed in averting its destructive consequences ; but any curative measures, for the removal of the osseous deposits or out-groAvths, and restoration of the disorganized state of the joints—in respect to ligaments, synovial membrane and cartilages, will have scarcely any avail. Local treatment—in the early stage—is that of synovitis. Rest of the joint, and slight topical depletion by a few leeches, may now prove efficacious. But, as the symptoms of inflammation subside, leaving some structural results —in thickenipg of the synovial membrane and effusion within the joint— counter-irritation, by means of blisters, or iodine paint, will become advantageous. Stimulant embrocations and friction, as by shampooing or local douches, and motion, may then succeed in recovering the use of the joints. The constitutional treatment should be that of rheumatism. In the early stage, bicarbonate of potash, in large doses, with wine of colchicum, may arrest the progress of the disease. Subsequently, iodide of potassium and guaiacum seem to have more controlling influence. Free action of the skin must be promoted by sudorific medicines, as Dover's powder and hot air-baths; while a rigorous attention to diet will be indispensable when the disease has a gouty character, with dyspeptic symptoms, denoting a constitutional origin of that kind. Mineral waters, coupled Avith a due observance of dietetic precautions, sometimes prove singularly beneficial in rendering joints supple and restoring the general health, at least for a time. The Avaters of Bath or Buxton in this country, Vichy, Wiesbaden, Carlsbad, Ems or Aix-la-Chapelle on the Continent, are thus hopeful resorts for the victims of chronic rheumatic synovitis. Scrofulous Synovitis.—Structural Condition.—A pulpy or gelatinous defeneration of the synovial membrane, resulting from inflammation of a chronic character, modified by a scrofulous constitutional condition. The synovial membrane, in this state, is thickened, and converted into a soft yelloAvish or light brown gelatinous material; more vascular also than the healthy membrane. This change may be partial in its extent, affecting only the membrane reflected over the ligaments, or over the cartilages. Sir B. Brodie, who first described this disease, relates such cases as shoAvn by dissection. The articular cavity becomes diminished as the thickening upon the inner surface of the membrane encroaches on the joint; and, this extension proceeding most freely in the loose synovial folds Avhich surround the cartilages, they are often concealed by the new p p 578 SPECIAL PATHOLOGY AND SURGERY. formation. A similar pulpy material forms in the areolar texture around the outer surface of the membrane, which thus becomes infiltrated and condensed. This gelatinous material—according to Mr. Barwell—results from a failure in the process of development of the products of inflam- mation ; in acute and healthy synovitis, a fibrous or areolar tissue being produced; whereas in scrofulous inflammation, development does not advance beyond the first form of crude cell-structure. Many intermediate gradations, however, may be found betAveen these two conditions. The knee-joint is most commonly affected. Signs, and Diagnosis.—In an early stage, a sense of stiffness of the joint is experienced and tumefaction appears, beginning almost imper- ceptibly, but slowly and gradually increasing; with absence of pain, even on moving the joint. These early symptoms are not very characteristic. In a more advanced stage, a very considerable enlargement is presented, generally of an irregular shape, colourless and elastic, without any distinct fluctuation. This disease most resembles scrofulous caries of the articular ends of the bone in the joint affected. But the swelling is diagnostic, in its being more obviously referable to the synovial membrane than to the end of either bone. From cancerous disease of either articular end of bone, the same feature of distinction may be available for diagnosis; while the whiteness of the skin contrasts with the reddish or purplish discoloration which sooner or later supervenes in malignant disease, as the skin becomes involved. The lymphatic glands also are not con- taminated. Course and Terminations.—As the disease progresses, the cartilages undergo ulceration in spots; though these spots are not, necessarily, at first, in direct relation with the pulpy synovial membrane. The changes which ensue are fully described in tracing the Ulceration of Articular Cartilages. Abscess forms within the joint, or in the substance of the swollen membrane ; and making its way to the surface, opens by various sinuous apertures. Hectic supervenes. Occasionally, the disease subsides by apparently a retrograde course of restoration. The gelatinous growth is directed inwards towards the articular cavity, which it tends to fill up ; while the material itself becom- ing more fibrous, and contracting, still further diminishes the cavity. Anchylosis of the osseous surfaces completes this process of recovery. Rarely, the synovial membrane itself is restored to a healthy state ; absorption taking place, and the articulation remaining structurally sound. Treatment.—Remedial measures must have regard to the constitutional condition, and hence the treatment of Scrofula is here appropriate. Local treatment consists, in absolute rest of the joint, and the observance of a suitable position in the event of anchylosis. Counter-irritation should be applied, cautiously. The actual cautery is, however, strongly recom- mended by Mr. Barwell, when enlargement is proceeding without any notable inflammation. The iron should be white hot, and applied in lines, about an eighth of an inch broad and three inches long, parallel to the axis of the limb. Four such lines are recommended for the knee, two on each side of the patella, at least an inch apart; dry lint being then applied. This proceeding resembles the "firing" of a joint, as practised in veterinary surgery. The advantage of counter-irritation, by means of the actual cautery and thus applied, is said to be not only its derivative effect, but the pressure which ensues from the contracting SCROFULOUS DISEASE OF THE JOINTS. 579 cicatrices. Scott's dressing may be used as a means of counter-irritation, and the plaster affords more support, when the SAvelling is reduced to a passive state. Friction and gradual motion will then finish off the disease, and restore the use of the joint. Ulceration of the articular cartilages, Avith abscess, and destruction of the joint, necessitate the removal of the diseased part, either by excision or amputation. The latter operation may be sometimes imperative, OAving to the constitutional exhaustion rather than the extent of the disease. Loss of limb will then be alternative to the loss of life ; the patient, otherwise, inevitably sinking under prolonged hectic. Scrofulous Disease of the Joints, or scrofulous inflammation and retries of the cancellated structure of the articular ends of Bone.— Structural condition.—The alterations of the cancellous structure in this state of disease, are fully described in Diseases of Bone. The changes alluded to may be summed up as inflammation and consequent caries; differing only from ordinary inflammation of bone in the nature of the products associated with the disintegrative transformation. At first, the cancellous structure is simply more vascular than natural, then it becomes softened, and porous; while the cancelli are filled with a reddish gelatinous fluid, and ultimately an opake, friable, tuberculous matter. Caries appears frequently in separate points of the cancellous tissue, Avhich gradually extending, coalesce. This disease is commonly situated in the articular ends of the long bones; particularly, the head of the femur, in scrofulous disease of the hip-joint; in the head of the tibia or loAver articular end of the femur, in similar disease of the knee-joint; in the bones of the tarsus; in those of the carpus; in connexion with the elbow or shoulder joints, occasion- ally ; and not unfrequently in the cancellous tissue of the bodies of the dorsal or lumbar vertebrae. Nor do these situations exhaust the list of bones liable to be affected by scrofulous caries. Signs.—Scrofulous caries of the knee-joint ma)' be taken as typical of the general symptoms. The disease approaches very insidiously, being preceded by little or no pain. Some inability to use the joint—a limping lameness in walking—first attracts notice. A child for example —the disease occurring commonly before puberty—drags his foot after him in Avalking. Weeks or perhaps months elapse ere pain is com- plained of; and then only a trifling pain, intermittent, but fixed, and aggravated by any movement of the joint, or especially on percussion of the bone below, and of the foot in disease of the knee-joint. This pain increases as the disease progresses. At length a swelling of peculiar character forms around the joint, arising from infiltration of the cellular texture Avith serum and lymph. A puffy, elastic SAvelling is thus pro- duced, which assumes a globular shape, while the skin retains its Avhite colour, constituting the " Avhite SAvelling," formerly recognised in Sur- gical Avorks. This swelling becomes more conspicuous and apparently larger than it really is, owing to gradual Avasting of the muscles above and beloAV the diseased joint. Scrofulous enlargement of the knee-joint, for example, thus differs notably in its characters from the swelling of Synovitis. The absence of pain in the first instance, and for a consi- derable period, is also diagnostic. In either disease, the limb becomes someAvhat flexed, from muscular action prevailing in that direction. The general health remains comparatively undisturbed up to this period. Course and Terminations.—Scrofulous caries of a joint may sub- pp2 580 SPECIAL PATHOLOGY AND SURGERY. side, leaving only some oedematous swelling and stiffness of the joint. Or, the disease progresses, both to the surface, and the interior of the joint. In the one direction, as the disease advances, the periosteum becomes detached, suppuration takes place around the joint, and sinus-openings form, leading down to worm-eaten carious bone, and giving vent to a foul discharge. The textures are undermined and traversed by sinuses in various tortuous ways, ac- cording to the anatomical rela- tions of the joint. (Fig. 217.) Towards the joint, as caries ex- tends, the nutrition of the car- tilages, depending on the osteal vessels, becomes impaired. Their attachment to the bone is loos- ened, and they acquire a fibrous character. Ulceration commences, usually, on the deep or osseous surface of the cartilages; as a disintegration equivalent to the carious state of the bone. Por- tions of cartilage may be de- tached and lie loose within the joint. Sometimes, the ulceration assumes a peculiar form, which has been named " spotted ulcera- tion ;" there being several pits containing a curdy matter in the articular surfaces, and which correspond to pits in the bone, while the intervening portions of cartilage remain unaltered. Ulceration of the articular cartilage is announced by painful startings of the limb, occurring particularly at night. Synovitis speedily super- venes, and the formation of matter within the joint. The opposite arti- cular cartilage becomes affected and the bone exposed. The two sensi- tive osseous surfaces meeting together and being subject to attrition and pressure by spasmodic action of the muscles, the starting pains are much aggravated. The ligaments share this destructive progress of the disease, and give way; the abscess within the joint bursts through the synovial membrane, and at length finds its way to the surface, with sinuous openings around the joint. The head of the bone, altered in size and shape, and no longer restrained by ligamentous connexions, undergoes dislocation; in whatever direction the disease may facilitate displacement, and subject to the action of the muscles. The joint has thus become irreparably disorganized; but anchylosis may take place without dislocation, or an imperfect joint form after dis- location, the bone remaining in its new locality. Either of these repa- rative terminations, in the course of nature, are rare. Constitutional disturbance of the most severe kind accompanies the destructive course of this disease; and the patient probably sinks ulti- mately from long-continued pain and sleeplessness, purulent discharge and the night sweats of hectic. The concurrence of scrofulous disease in other organs, than the joints, must not be overlooked in our prognosis. Thus, the lungs or mesenteric glands may be affected with tubercular deposit; or tubercular meningitis ensue, with effusion into the ventricles of the brain. And SCROFULOUS DISEASE OF THE JOINTS. 581 the social state of the individual should be taken into account; scrofu- lous disease arising and progressing far more readily in the poor and needy, than in the affluent classes of society. Treatment.—Local appliances are of subordinate importance to con- stitutional treatment, yet they are co-operative in arresting scrofulous caries and the reparation of its destructive consequences. In the first place, absolute rest of the limb is an essential condition throughout this disease ; in the earliest stage to arrest its progress, sub- sequently to relieve pain and induce anchylosis. Due regard should also be had to the position most favourable for the future use of the limb, in the event of this issue. Such rest, and position, can only be secured by means of a suitable splint. A leather or gutta-percha splint moulded to the joint answers best, generally. But the splint must be of sufficient length to fix the limb entirely, and check, any contraction of the muscles which would affect the joint. Thus, in scrofulous disease of the hip-joint, a gutta-percha splint should be applied so as to embrace one side of the pelvis and tAvo-thirds of the circumference of the thigh, and extend from the short ribs to below the knee. The limb should be in a line with the trunk, or bent only slightly forwards. For the knee- joint, two lateral splints are preferable; supporting two-thirds of its circumference, and extending from the middle of the thigh to the middle of the leg. A slightly flexed position will be the most convenient in the event of anchylosis. For the ankle, also, two lateral splints may be made to include the lower part of the leg and the sole of the foot; the patient being allowed to walk about with the knee supported by a Avooden leg. Disease of the bones of the foot, will require the support of a splint moulded to the sole, and turned round the inner and outer side. Over this, a large cloth boot may be worn, Avhereby the patient can walk about without injury to the diseased joints. In the upper extremity, scrofulous disease of the joints must be treated on a similar principle as to rest, and position. For the shoulder, a splint should be moulded to the joint, and extend down the arm to the elbow; the fore- arm being suspended in a sling from-the neck. A diseased elbow-joint is best supported by lateral splints ; the wrist by a splint on its palmar surface, extending upwards to near the elbow and downwards to the tips of the fingers, and doubled at its margins over the sides of the hand and forearm. In an advanced stage of the disease, when painful startings of the limb, and a tendency to dislocation have supervened; it becomes advi- sable to slightly separate the diseased articular surfaces, and counteract muscular contraction. Some extending force, moderate but constant in its operation, may be advantageously resorted to. For the hip-joint, Liston's long splint, interrupted, will accomplish this purpose. The knee-joint is, perhaps, best managed by a pulley sling-apparatus which encloses the limb in a canvas-trough; while slight extension is main- tained by the inclined direction of the pulleys. This apparatus—appli- cable also to fracture of the thigh or leg—gives great ease and comfort in advanced disease of the knee-joint. Other joints may be subjected to contrivances Avhich seem most effectual. Lastly, whatever be the termination of scrofulous caries, a starched bandage is an exceedingly useful support. If the disease be arrested, leaving only some oedematous swelling of the joint; the uniform pres- sure of this support will aid in reducing the swelling, and the patient 582 SPECIAL PATHOLOGY AND SURGERY. can get about on crutches—supposing the lower limb to be affected— with the benefit of air and exercise. If anchylosis have ensued, or a new joint as the result of dislocation ; the support of a starched bandage will be equally advantageous. The period of time necessary for the use of some support to the seat of disease is always considerable; many months, possibly years. Other local treatment—from first to last—may be regarded as com- paratively unimportant. Scrofulous disease of a joint cannot be arrested by any depletory measures, and in proportion as they reduce the general health such measures are positively injurious. Local blood-letting, by a few leeches, may sometimes prove advantageous in the incipient or vas- cular stage of the disease. But the repeated loss of blood would be injurious. Counter-irritation, by blisters, setons, &c, has an equally restricted applicability. The discharge and pain they occasion, more than counterbalance any good resulting from their derivative action, especially in children. If the disease subsides, with oedematous SAvelling; stimulating applications have some beneficial influence. Hence, embro- cations, iodine paint, and douches of sea-water, are now useful. Pressure also—as by a starched bandage, or pressure with stimulation—by Scott's strapping, may be applied with advantage. Abscess having formed—as the disease progresses ; a free and depen- dent opening should be made in time to prevent burrowing of the matter. The starched bandage can still be used, with a trap-opening opposite the abscess, for the convenience of dressing and cleanliness. The local treatment of scrofulous caries of a joint, thus generally resembles that of synovitis; in respect to rest and position of the joint, topical applications, and the treatment of abscess. But the constitutional treatment of this disease is precisely that of Scrofula. This treatment consists in a course of tonics, especially the preparations of iron and quinine, a nutritious diet, including cod-liver oil, pure air, daily exercise, and sea-bathing. The administration of medicinal tonics should be varied from time to time, and with occasional intermissions. For children, the vinum ferri seems preferable, and after a while the syrup of the iodide of iron may be given in exchange; these and other simple preparations of iron being continued for three or four weeks, and then omitted for a week or ten days. But this course of treatment must be extended over a considerable period, probably two or three years. Ulceration of Articular Cartilages.—Structural condition.—The articular cartilages, when fully developed, and in a healthy state, are destitute of blood-vessels (and nerves). Nutrition is effected—as in the cornea—by imbibition ; the nutrient matter being drawn from the blood- vessels of the subjacent bone and vascular fringe of the synovial mem- brane around the circumference of the cartilage. As the result of in- flammation—according to the observations of Sir B. Brodie, Mayo, and Liston—blood-vessels extend into the cartilages from the subjacent bone; just as they form in extravasated lymph. Hence the nutrition of articular cartilages, in this state, depends on a supply of nutritive matter, directly from the vessels, as in other Avascular textures. But this question of the vascularity or non-vascularity of cartilage—with regard to the more or less direct supply of blood, has nothing A\rhatever to do with the nutritive process itself as pertaining to the elemental structures, in health and disease. In regard to ulceration of the articular cartilages, the researches of Goodsir and Redfern, more particularly, have shown, that it represents ULCERATION OF ARTICULAR CARTILAGES. 583 a vital alteration in the cartilaginous structure itself; and that the influence of the neighbouring blood-vessels is only indirect or secondary. As consequent on inflammation of the synovial membrane—synovitis, or of bone—ostitis, ulceration of articular cartilage may be named inflam- matory ulceration, or secondary, in its relation to the original disease. Similar ulceration may also occur as an original disease of the cartilage, and is hence named primary ulceration. But this state would seem to be, usually, a degeneration. Degeneration precedes inflammatory ulceration when the disease originates in bone, and extends to the cartilage as a secondary affection. Ulceration may begin, either on the free surface of articular cartilage, or on its attached surface; and at its margin, where the synovial mem- brane is reflected over it, or in the substance of the cartilage. In the hip, it may commence close to the attachment of the round ligament; or in the knee, adjoining the crucial ligaments. Forming shallow excavations, these assume the appearance of grooves, at a greater or less distance from the margin and frequently in the central parts of the cartilage. Nearly the whole cartilage may disappear, leaving only a few isolated reddened patches. Inflammatory ulceration—consequent on synovitis, presents the follow- ing alterations, on the free surface of the cartilage. The colour of the cartilage is altered in spots; which either rapidly become holes, as if cut out with a chisel, or the spots assume a fibrous aspect, and becoming excavated, form pits with fringed margins. Thus, the cartilage may be extensively destroyed, and the bone laid bare. Or, and especially in scrofulous synovitis, a thick vascular membrane forms, which passes from the diseased synovial membrane over the cartilage. The cartilage—as Mr. Barwell describes it—slowly undergoes transformation into a kind of granulation, between which and a similar material growing from the synovial membrane, adhesions ensue, resulting in absolute continuity. When ulceration of the cartilage has extended deeply, the bone becomes involved, and the cancellous tissue acquires undue vascularity. The articular lamella of bone—a layer of calcified cartilage—crumbles or breaks up in masses, carrying with it portions of cartilage; and the granulations springing from the exposed cancellous tissue unite with those of the synovial membrane. Ulceration consequent on disease of the subjacent bone, consists— according to Mr. Bai'Avell—in degeneration, followed usually by inflam- matory ulceration. A portion of the cartilage, losing its nutrient supply, degenerates or perishes, and is detached with its articular lamella from the inflamed surface of bone ; whilst the surrounding portions of cartilage undergo the changes described as occurring in ulceration from synovitis. The minute changes in this process of ulceration relate both to the cartilage-corpuscles and the inter-cellular or hyaline substance. The corpuscles enlarge, Avith an endogenous development of cell-structures, and bursting, discharge their contents into cavities in the tissue itself, or upon the free surface, mingling Avith the organic matters contained within the joint, and probably forming pus. This endogenous productiveness is greater, the nearer to the seat or focus of disease. There, instead of tAvo or three nucleated cells, the corpuscles may contain an almost indefi- nite number of younger cells, resembling pus-globules. The inter-cellular or hyaline substance undergoes disintegration, or in more chronic ulcera- tion it becomes split into bands or fibres of varying size, in the midst of 584 SPECIAL PATHOLOGY AND SURGERY. which, sometimes, are found gelatinous masses; the changed contents of the cartilage corpuscles as Dr. Redfern supposes. These changes occur more or less rapidly in proportion to the activity of the disease; thus representing the acute and chronic varieties of ulcera- tion. In one case, the patient having died after venesection, Mr. LaAV- rence believed that complete destruction of the articular cartilages of the femur and tibia took place in four days. Chronic ulceration may progress very slowly, especially when of rheumatic origin. Signs and Diagnosis.—(1) Secondary ulceration of the articular car- tilages is announced by the starting pains adverted to in connexion with the progress of synovitis and scrofulous caries; and the articular disease is preceded by the symptoms of one or other of these diseases. (2) Pri- mary ulceration, of an inflammatory character, presents certain special and distinctive signs, as compared with synovitis or caries. Pain, fixed and intense, is the earliest symptom, and coincident with the commencement of the disease. This pain is aggravated by movement of the joint or friction—rather than by percussion of the bones—and accompanied with startings of the limb, as muscular spasms supervene. In the course of weeks or months, slight swelling arises, corresponding in shape to the margin of the affected cartilages, and produced by serous effusion into the cellular texture externally. Abscess, within the joint, follows. Repair—after ulceration of articular cartilage—takes place in different ways. ExtensiA-e destruction of the opposed cartilages, with exposure of the cancellous bone; may be followed by the formation of granulation- tissue, uniting the osseous surfaces, and resulting in anchylosis. Ulcera- tion affecting the cartilage to a considerable depth is sometimes re- paired—as Redfern describes—by the formation of a fibro-nucleated membrane from the substance of the cartilage, without the occurrence of any new exudation. Occasionally, a patch of ivory-deposit or porcel- lanous-encrustation, occupies the place of a portion of cartilage; or a scar alone marks the seat of a former ulcer. Treatment.—The local treatment is the same as for other inflammatory diseases of the joints. Absolute rest, and position of the joint, must be observed, and for a considerable period. Counter-irritation, by blisters, issues, or caustic potash, may be applied more advantageously than in scrofulous caries. Abscess must be opened forthwith, and anchylosis induced, as the only favourable termination in this advanced state of the disease. Excision or amputation are ulterior resources, which will be considered wtih reference to Diseases of the Joints, specially. (Chapter XXXVII.) The constitutional treatment resembles that for rheumatism affecting the joints. Mercury, in the form of calomel, the bichloride, or blue-pill, combined with opium, should be administered, and pushed to slight salivation. Mercurial inunction must be resorted to, if the internal administration disagree. This may be followed by iodide of potassium and sarsaparilla. But subsidence of the joint-symptoms will soon declare whether the articulation itself is preserved, or anchylosis be inevitable. Anchylosis, or Stiff Joint.—Structural Conditions.—Two states of anchylosis are recognised; the fibrous or incomplete; and the osseous or complete. Both signify the junction or union of the articular surfaces of the bones, thus presupposing the partial or complete removal of the articular cartilages; unless occasionally, in fibrous anchylosis, where bands of false membrane may be thrown across the synovial capsule, forming adhesions, with some stiffness of the joint. Either condition of ANCHYLOSIS, OR STIFF JOINT. 585 anchylosis may be extracapsular; the fibrous consisting of a thickened and indurated state of the ligamentous capsule, with adhesions around the joint; and osseous anchylosis externally, being the formation of new bone around the joint. (1) Fibrous anchylosis is liable to happen to any joint; and the shortened and contracted state of the muscles acting on the joint gives an apparent firmness to the anchylosis, beyond that due to the joint- condition. (2) Osseous anchylosis occurs most Fig. 218.* commonly in the hip, knee (Fig. 218), or elbow; the articular sur- faces seeming to be fused together, as seen more clearly on a vertical sec- tion of the bones. Both states of anchylosis are attended with a proportionate loss of mobility in the joint; the fibrous allows of some degree of motion, more so, perhaps, under chloroform ; the osseous presents a perfectly rigid and immovable joint. Both anchyloses are also accom- panied with more or less deformity of the limb, arising from mal-position of the bones obediently to muscular contraction; unless the anchylosis has resulted under proper and effectual surgical supervision. The Causes of anchylosis have reference to inflammatory diseases of the joints ; synovitis, caries, and primary ulceration of the articular cartilages, as already described. Destruction of the cartilages thence ensuing, may be succeeded by reparation, in the form of anchylosis. The fibrous state represents the incomplete result of reparation ; the osseous state, its com- pletion, by the transformation of the fibrous matrix into bone. Treatment.—Preventive measures consist in the prompt and efficient treatment of the diseases leading to anchylosis; while the precaution should also be taken of securing the limb in such position as shall be most useful in the event of this result. Remedial treatment consists, in restoring, if possible, the mobility of the joint, and correcting any deformity of the limb. Or the latter may be the main object in view. Fibrous anchylosis—admitting of some motion in the joint—commonly yields to passive motion, from time to time; thus gradually regaining the use of the joint. Firmer union will, probably, have to be overcome by forcible flexion and extension, under the influence of chloroform. The joint yields with a creaking cleavage and successive snaps, which are both heard and felt. Any resisting tendons may be divided subcutaneously, tenotomy completing the cure. The knee or elbow-joints, for example, can thus be restored to a fair degree of mobility, and the limb brought to a good position. When these manipulative or operative procedures have failed ; if then the fibrous anchylosis be incompatible with a good use of * Bony Anchylosis of Knee-joint, with extreme mal-position—tibia forward at right angle with femur. (A. Cooper.) 586 SPECIAL PATHOLOGY AND SURGERY. the limb, as in the case of such anchylosis of the knee-joint; excision of the joint may advantageously be resorted to ; and the more so, in propor- tion to mal-position of the limb. Osseous anchylosis cannot be overcome by any justifiable force of ex- tension. If, therefore, the limb be comparatively useless, as in the case of the elbow-joint, excision must be had recourse to. The removal of a wedge-shaped portion of bone above or below in connexion Avith the anchylosed joint, may be necessary to correct an angular deformity of the limb in the case of the knee-joint. In any case of osseous anchylosis, the propriety of excision will also depend on the mal-position of the limb which may accompany the anchylosis. Amputation will be warrantable only in the extreme case of a useless limb, and which cannot be made tolerably serviceable by excision. Loose Cartilages in Joints.—Small moveable bodies occasionally form within a joint, and which may be quite free, or attached by narrow peduncles to the walls of the articular cavity. One such body sometimes exists, but not uncommonly two or three, and possibly, many. In the left knee of a woman who died of apoplexy, Morgagni found twenty-five smooth and polished globular bodies. Varying in size from a barley-corn to a chestnut, they are roundish or flattened, elongated or tuberous. In consistence, colour and structure, these bodies may be soft and of a yellowish colour, like little masses of fibrine; or hard, whitish and glistening, consisting of cartilage or fibro-cartilage; or converted into bone. Neither the term " cartilage " nor " loose," is, therefore, universally applicable. Any joint possibly, may be the seat of these bodies; but they occur usually in the knee, and less frequently in the elbow, shoulder, or lower jaw. They seem to arise from the vascular processes of the synovial mem- brane, as out-growths of that membrane, projecting into the joint. They remain connected, or become detached, and are liable to undergo the changes of appearance and structure, above described. These cartila- ginous bodies form most frequently as the result of chronic rheumatic synovitis; and more often in adults than at an earlier period of life. Other modes of origin seem probable in some cases. Thus, the fibrinous concretions may, perhaps, represent exudations, or precipitations from the synovia. Portions of bone becoming detached from the articular surfaces, or resulting from ossific deposit, give rise to similar symptoms. Symptoms.—It will be readily supposed that any such foreign body getting nipped in between the articular surfaces, must occasion some remarkable symptoms. Hence, an attached cartilaginous body may re- main quiescent; a detached, or entirely loose cartilage, moving about in the synovial capsule, is more apt to slip in between the bones. Up to this time the patient may have experienced occasional twinges, as if of rheumatic character; but now a sudden, intense, and sickening pain seizes him ; and the joint becoming instantly locked, the hitching or fixed inability to move the limb, may throw him to the ground in the act of progression. Sudden dislodgment of the intervening cartilage is equally apt to occur, whereby the joint is immediately restored to its original state of painless mobility ; leaving only perhaps a little temporary effusion. These symptoms having recurred at intervals, on the slightest movement, and sometimes during sleep; the sufferer seeks relief. On careful exami- nation, a foreign body can usually be found, and by palpation brought TUMOURS CONNECTED WITH JOINTS. 587 perhaps to a stand-still at the edge of the patella—in the knee-joint, and there made to bulge under the skin; but the little smooth cartilage easily Blips aAvay from under the finger and again disappears. Ultimately, the joint itself sometimes becomes diseased; prolonged irritation inducing synovitis with relaxation of the ligaments, which are loosened also by having been stretched by the repeated interposition of the cartilage between the articular surfaces. Treatment.—Recurrence of the attacks of pain may be prevented by limiting the motions of the joint; thus fixing the loose cartilage, tempo- rarily, or perchance permanently. Hence, an elastic bandage or knee-cap should be constantly worn. Often the relief afforded is such that no further interference becomes requisite. Removal of the foreign body, is the only other resource; but this should never be lightly entertained, considering the risk to the joint and even to life, contingent on the operation of extraction. It is justifiable only when the cartilaginous body is loose, and freely moveable, of some size, and apparently single. Taking a favourable opportunity—after the pain and irritation of an attack have subsided—this operation may be per- formed, in either of three ways. It is more difficult than would appear to one who has not done it. The cartilage must first be carefully fixed, in a steady spot, with the forefinger and thumb. In the knee, it may be made to project on one side of the patella. The skin is then to be drawn to one side, and an incision made directly down upon the cartilage, which is thence allowed to escape. On relaxing the skin, the valvular aperture is at once closed with a strip of plaster, and the limb should be kept at rest until any symptoms of synovitis have subsided. Another mode of operation, consists in introducing a tenotomy knife slantingly underneath the skin and dividing the synovial capsule upon the fixed cartilaginous body; then squeezing it through the synovial aperture into the external cellular texture, where it is allowed to remain, the integumental aperture is closed with a strip of plaster. If the car- tilage should not become absorbed, it is extracted from its bed by a sub- cutaneous incision, when the synovial aperture has healed, after the lapse of some days. Both these methods of operation are hazardous; but the subcu- taneous one is less so than the immediate mode of extraction, as would appear from a large number of cases the results of which were compared by M. Larrey. In 167 cases of removal of loose cartilages by operation ; 121 Avere cases of the direct operation, and 98 were successful, 5 doubtful, and 28 died; Avhilst of 39 subcutaneous operations, 19 were successful, 15 failed, and 5 died. A modification of the subcutaneous operation has been practised by Mr. Square of Plymouth ; and by Avhich Mr. Erichsen states that he has successfully removed in succession five loose cartilages from one knee. The capsule having been divided subcutaneously over the fixed cartilage, it is pressed into—not through—the synovial aperture, and retained there by a compress and strips of plaster. Adhesion speedily ensues, followed by absorption of the cartilage. Mr. Syine recommends yet another method, by Avhich, he says, he generally succeeds Avithout risk. It consists in "making a free subcu- taneous incision through the synovial membrane and cartilage, and apply- ing a blister over the part Avhere it is retained." Tumours connected with Joints.—Cancer of the Articular ends of 588 SPECIAL PATHOLOGY AND SURGERY. Bone is sufficiently described in connexion with Cancer of Bone gene- rally. " In cartilage " observes Virchow in his Cellular Pathology, " malignant affections are so rare, that it is usually assumed to be alto- gether insusceptible of them." The synovial membranes are equally in- disposed to cancerous disease. Sir B. Brodie states, that he had " no reason to believe that any truly malignant disease ever has its origin in the synovial membrane." For other Morbid Growths in the articular ends of Bone—see Tumours of Bone. Neuralgia of Joints is specially important in relation to the diag- nosis from structural disease—see affections of the Nerves. CHAPTER XXXV. diseases of particular joints. Diseases of the Hip-Joint.—The hip-joint is liable to the same inflam- matory diseases as other joints, affecting its component structures; synovitis, scrofulous caries, and ulceration of the articular cartilages. The second-named disease presents characters worthy of a separate description. Scrofulous Disease of the Hip, or Morbus Coxarius.—Structural condition.—This disease commences in the cancellous tissue of the head of the femur, or of the acetabulum; possibly, in both bones simultane- ously. It may also commence in the synovial membrane, as scrofulous synovitis; or, it is said, in the round ligament. Hence, the name, scro- fulous disease of the hip, as a general term including these different seats of origin. In scrofulous caries of the hip, the cancellous tissue undergoes the structural alterations described in connexion with this disease of Bone; briefly, increased vascularity, softening, deposition of a reddish fluid in the enlarged cancelli, followed by a yellowish opake tubercular matter. Subsequent structural alterations are as follow:—The articular car- tilages become involved and disappear, more or less completely; and abscess forms within the cavity of the joint. The affected portions of bone become remarkably changed in shape and size. The head of the femur—bared perhaps of cartilage and the open cancellous tissue ex- posed—is flattened and expanded, mushroom like in form on the neck of the bone ; and the neck itself sharing in the disease, may be so reduced, as to leave nothing more than a slight nodular vestige, if any remnant, of the diseased bone projecting from the great trochanter. This portion of the bone, and the adjoining portion of the shaft, are not unfrequently carious; either by an extension of the joint disease, or as the original seat of caries. The acetabular cavity, also denuded of cartilage, is en- larged in circumference, but shallow; the cotyloid ligament and bony rim of this cavity having been destroyed. The round ligament may have disappeared, and the capsular ligament at length giving way, the abscess bursts into the surrounding cellular texture. Thus the joint is utterly destroyed. Terminations.—(1) Anchylosis rarely takes place, as a mode of repa- ration. (2) The remnant of the articular end of the femur is drawn up SCROFULOUS DISEASE OF THE HIP, OR MORBUS COXARIUS. 589 by the action of the muscles into the patulous acetabulum. Thence the femur has even been forced through the thinned carious bottom of this cavity, and entered the pelvis. (3) But the ill-fitting, loose, articulation from advanced disease, is mostly liable to dislocation. The femur drawn upwards and outwards by the glutei muscles, passes over the reduced brim of the acetabular cavity, and slipping on to the dorsum ilii, lodges there. More rarely, the femur is thrust out of the acetabulum forwards, and rests on the ramus of the pubes. Abscess finds its way to the surface by burrowing sinuous tracks, and opens in various situations. The openings relate somewhat to the seat of the disease. When it originates in the head of the femur, the sinus extends some way doAvn the thigh, and opens probably near the insertion of the tensor vaginae femoris muscle. Acetabular disease presents a sinus-opening in the gluteal region near the anterior inferior spine of the ilium. Matter may also pass down by the rectum, bursting into it, or close to the anus. If the pelvic bones be involved, a sinus opening is presented in the pubic region, above or below Poupart's ligament; above the ligament, it leads probably to intra-pelvic abscess; below the ligament, to disease of the rami of the pubis or ischium. Sign3.—(1) Scrofulous disease of the hip-joint approaches, and pro- gresses, very insidiously. Commencing generally in early life, under the age of puberty, scarcely any pain is complained of in the first instance, or for weeks, possibly months, as the disease slowly progresses. The first perceptible sign is a slight limp in walking; the child shuffling, hobbling, or dragging his leg, step by step. When standing still, the whole weight of the body is throAvn on the other limb, to relieve the halting member. This attitude is peculiar; the hip of the sound limb being elevated, gives an obliquity to the pelvis downwards on the diseased side; the thigh is slightly bent on the pelvis, and the leg on the thigh, the toes touching the ground. The limb may be somewhat abducted and everted, the toes being turned outwards; in this particular resem- bling dislocation on the pubes, or fracture of the neck of the femur. But, in the first stage of diseased hip-joint, the limb is apparently elon- gated. This, however, is a deceptive appearance, arising from the obli- quity of the pelvis downwards towards the diseased hip; measurement with a tape from the anterior superior spine of the ilium to another fixed point below the joint, the inner malleolus, will at once show that there is no elongation in reality. The limb becomes wasted, from disease, the gluteal muscles especially; so that the buttock is flattened and flaccid, wider than natural, and the lower fold of the nates less marked. Pain is noAV felt in the hip, or referred more to the inner side of the knee ; and the pain in the former situation is aggravated by any attempt to bear on the joint, by abduction, or rotation of the limb, and especially by concussion of the bones, as by striking the trochanter or jerking the limb upAvards from the sole of the foot. Pain on the inner aspect of the knee is a sympathetic sensation; depending, probably, on the nervous relation betAveen the hip and knee, through the obturator and perhaps the anterior crural nerves. Both these nerves supply articular branches to the hip, and to the inner side of the knee. (2) Real shortening of the limb—succeeding its apparent lengthening __marks the second stage, as it has been termed, of this disease. It coincides Avith advancement of the disease to destruction of the cartilages and of the head of the femur, acetabulum, or both bones; whereupon 590 SPECIAL PATHOLOGY AND SURGERY. the limb is draAvn up by muscular action. Shortening varies, therefore, in different cases, but it increases as the disease progresses. The attitude of the limb is somewhat changed; still remaining flexed, it has now also become inverted; in this particular resembling dislocation backAvards on the dorsum ilii or into the ischiatic notch. Lateral inclination of the pelvis has, at length, produced a compensatory lateral curvature of the spine. Wasting of the limb increases. This shortened, flexed, inverted, and wasted limb; with obliquity of the pelvis and twist of the spine; present a very characteristic appearance. Pain also has become more severe, and aggravated by the attrition of the exposed surfaces of bone, subject to spasmodic muscular action, has acquired the character of starting pains. Abscess within the joint bursts into the surrounding cellular texture, and forms a swelling in connexion with the hip; Avhich up to this time had undergone no further alteration than a slight fulness in the groin, and enlargement of the inguinal glands. Abscess-swelling is rendered more conspicuous by the wasting of the thigh and buttock. When, at length, the abscess opens externally, the situation of the sinus apertures denotes, as already indicated, the probable seat of the disease; whether in the head of the femur or acetabulum. Dislocation is very apt to supervene; commonly on the dorsum ilii; yet, although attended with increased shortening, the attitude of the limb, flexed and inverted, re- mains the same. But the head of the femur or its remnant, with the great trochanter, can be felt in its new situation, on the back of the ilium; and often very distinctly, the gluteal muscles having -wasted so much that the bone seems to lie immediately under the skin. The additional symptoms—wasting of the limb, and sinuses discharging an unhealthy pus and leading down to diseased bone, complete the local diagnostic differences of appearance from traumatic dislocation. The general health also has now become worn down by irritation and hectic; and this constitutional condition, coupled with that of the diseased limb, form a picture which leaves little or no doubt as to the nature of the case, not to mention the previous history of its insidious origin. Diagnosis.—Scrofulous disease of the hip-joint is liable to be mis- taken for other diseases, if any one particular symptom be alone consi- dered. It may resemble rheumatism, disease of the knee, lateral curva- ture of the spine, infantile paralysis with wasting and defective growth of the limb, psoas abscess, abscess near the joint, inflammation of the bursa under the psoas-iliac muscle, and congenital dislocation of the hip-joint. But the concurrence of symptoms, and as compared with those of each of these diseases, will determine the diagnosis. Treatment.—The directions given with reference to scrofulous disease of the joints generally, are here applicable ; rendering any repetition of detail unnecessary. Absolute rest of the joint must be secured, and a position favourable to the future use of the limb, in the event of anchy- losis. A splint moulded to the hip and extending below the knee, with the limb straightened, will best answer this twofold purpose. Subse- quently, the long straight extending splint may be applied with more advantage ; thus to counteract muscular spasm and pain coincident Avith ulceration of the cartilages in contact, and the liability to dislocation as the disease advances. The accompanying extending apparatus is said to answer admirably; but I have had no experience of its use. (Fig. 219.) It is a combination of the leathern hip-splint advocated by Sir B. Brodie, SCROFULOUS DISEASE OF THE HIP, OR MORBUS COXARIUS. 591 with Dr. Davis's metallic lever; but the simple manner in which it is made to control any rotative or abducting movement of the limb, is peculiar. Fig. 219. Fig. 220. Contraction of the hip, taking place subsequently, may be counter- acted by the annexed apparatus (Fig. 220), Avhich successfully combats each abnormal mal-position of the limb. The pelvic band bears two lateral uprights, upon which the armpits rest, and from which strong laced bands pass around the thorax. This instrument is especially adapted for cases of severe hip-contraction. Abscess should be opened to prevent burrowing of the matter among the muscles. The situation of pointing is selected, usually about an inch above and behind the great trochanter. For the convenience of dressing, a long " interrupted " splint may be used. The general treat- ment, medicinal and hygienic, consists, in a course of iron, quinine, cod- liver oil, and nutritious diet, with as much pure air as possible. I have very beneficially placed my hospital patients in bed in the quadrangle of the hospital, for some hours daily, weather permitting. This plan of treatment must be pursued for a considerable period— some weeks or months—to solicit anchylosis; or the subsidence of the disease, possibly, after dislocation, and a free discharge of matter with the detritus of the carious bone. Failing thus to bring the disease to a termination, and the general health declining, operative interference becomes imperative. This will be considered under Excision of the Hip. 592 SPECIAL PATHOLOGY AND SURGERY. Chronic Rheumatic Synovitis or Arthritis—Morbus Cox.£ Senilis. —Structural Condition.— This disease contrasts Avith scrofulous disease of the hip-joint, principally in the formation of osseous depositions or outgrowths around the joint, and in the absence of suppuration. Signs, and Diagnosis.—The former structural difference gives to the neck of the bone an enlarged and irregular character; which, hoAvever, can scarcely be detected, as a sign, at the bedside. But the dry character of this disease,—the absence of suppuration in the joint, and its conse- quences,—the swelling of abscess and the discharging sinuses which ensue, are perceptiby distinctive. Shortening of the limb to some extent occurs, as the disease advances to destruction of the articular cartilages, with expansion of the head of the bone, and lowering of its neck to even below the level of the great trochanter. The disease progresses slowly, and is thus clearly distinguished from the sudden result of fracture. Other articulations being or becoming affected, would leave no doubt as to the nature of this condition. The general health is often little disturbed, the disease appearing as a local affection. It seldom occurs under the age of forty ; differing in this respect from scrofulous disease of the joint, as well as in its pathology and consequent symptoms. Treatment—see Chronic Rheumatic Synovitis. Neuralgia of the Hip.—The diagnostic Symptoms of Neuralgia are pointed out in connexion with affections of the Nerves. Neuralgia of some duration is attended with the alterations of atti- tude consequent on disease of the joint—whether scrofulous or rheu- matic. The weight of the body being habitually thrown on the sound limb to relieve the affected joint of the other side, the limb on this side becomes apparently lengthened and flexed, the toes touching the ground; the pelvis is inclined obliquely to the same side, and some compensatory lateral curvature of the lumbar spine results. But, with neuralgia, no real shortening of the limb ever ensues. Disease of the Sacro-iliac Joint.—Structural Condition.—The cartilaginous lamella of the sacro-iliac articulation seems to be the seat of a disease, occasionally affecting this joint. Ulceration of the carti- lage, as the primary change, involves the synovial membrane; both of which structures are thus destroyed more or less completely. But, the ligaments remain unaffected, or are only partially destroyed ; and the adjoining osseous surfaces do not become carious or necrosed. This disease is of very rare occurrence. It is, hoAvever, particularly noticed by Nelaton and Erichsen. Signs, and Diagnosis.—Pain is one of the earliest symptoms. It is confined to the region of the joint, and increased by any movement or position whereby the weight of the body is thrown upon the sacro-iliac joint. Thus, walking, stooping, or even standing, is attended with a sense of painful weakness in that situation, and as if the body were falling asunder. When the pelvis is at rest, the hip maybe moved in any direc- tion without pain. It acquires a gnawing or rheumatic character as the disease advances. Inability to support the weight of the body, occasions an insecure, wriggling gait, from side to side; thus differing from the dragging lameness of the limb in disease of the hip-joint. Swelling makes its appearance over the joint; it is pulpy and elastic, and of an elongated shape in the line of the articulation. The limb is apparently elongated, owing to a drooping of the pelvis on the diseased side, the limb being DISEASE OF THE SACRO-ILIAC JOINT. 593 disused to support the trunk ; and this side of the pelvis is tilted forwards. Consequently, the anterior superior spine of the ilium, is both on a loAver level and more prominent forwards, than on the sound side. Measure- ment, however, from that prominence to the inner malleolus shows that the limb is not elongated,—that any apparent lengthening—say half an inch, is not due to any change in the three large joints, or in the bones of the limb ; but that it must depend on some alteration aboAre the anterior superior spine. Usually, the limb is straight, and becomes wasted as the disease progresses. Abscess occurs at a late period. It forms over the diseased articu- lation, but spreads in various directions. The matter may point pos- teriorly near the articulation, passing upwards perhaps to the loin, upon and just above the crest of the ilium, there forming a fluctuating swelling of considerable size ; or extending outwards over the buttock, it reaches forwards nearly to the trochanter, as a great gluteal abscess. In both these situations, lumbar and gluteal, the abscess is extra-pelvic. Intra-pelvtc abscess, the matter accumulating within the pelvis, may pass out of the sciatic notch, and thence under the gluteal muscles; or gravitate down- wards into the ischio-rectal fossa, and present by the side of the rectum, or vagina ; or open into the rectum and discharge per anum. Shortening of the limb takes place, in consequence of, and proportionate to, the destruction of the sacro-iliac articulation. In one case, related by Sir B. Brodie, the ilium seemed displaced and draAvn upwards, so as to shorten the affected limb by two inches. The diagnosis will have to be made—as Mr. Erichsen observes— between this disease, and that of the hip, disease of the pelvic bones, spinal disease, neuralgia of the hip, and sciatica. Causes.—Acute inflammation of this articulation may result directly from injury ; as in a case given by Louis, a sack of corn having fallen on the loins of a man who was stooping at the time. In Sir B. Brodie's case, the symptoms seemed referable to pregnancy, four years previously. The disease has a scrofulous origin—according to Mr. Erichsen's expe- rience ; but he has never seen it in young children, only in young adults from fourteen to thirty years old. I have met with one case only, of this disease, of which the history, by my notes, was briefly as follows. F. H. H., aged eight, a weakly child from birth. The mother states that her four other children all died of water on the brain. Five years ago, this child fell down a long flight of stairs. Four months subsequently, she limped from side to side, in Avalking, like the motion of a milk-girl in carrying her pails. Shortly afterwards, she had intermittent fever, Avhich lasted about two months. She met Avith a second fall down a flight of ten steps, and afterwards the limping gait became more marked. Then, the right gluteal region was ob- served by her mother, to be larger than on the left side. For two years she continued to Avalk on crutches. During this period, some slight curvature of the spine had taken place, in the loins, and a spine-support was put on by a surgeon at the Orthopaedic Hospital, in Oxford Street. A swell- ing presented near the vagina, on the right side, and that in the gluteal region remained. In April, 1866, she was admitted to the Royal Free Hospital. The symptoms Avere those of the disease in an advanced stage ; abscess occupied the Avhole of the buttock, and pointed near the vagina; thus bein«- both extra-pelvic and intra-pelvic. Shortening of the limb, to a slight extent, had occurred, above the anterior superior spine of the ilium. ° Q Q 594 SPECIAL PATHOLOGY AND SURGERY. The Course of this disease, as already indicated, is most unfavour- able ; and thence the prognosis, is equally so. Continuing for months or years, the termination is nearly always fatal. In Sir B. Brodie's case, however, although shortening had occurred, recovery ensued. Treatment.—The same treatment, local and constitutional, as for disease of the hip-joint, represents the little that can be done in disease of the sacro-iliac articulation. Removal of the diseased articular surfaces, by excision, is, of course, out of the question. CHAPTER XXXVI. deformities. This large branch of Surgery forms the subject of several special Treatises. An abstract only—so far as the present discordant opinions respecting much of the pathology and treatment of Deformities, will allow—can be "iven here; sufficient for the requirements of the general Student, and for reference, in accordance with the design of this work. Deformities may be arranged in two general classes :—1, Acquired Deformities ; 2, Congenital Deformities or Malformations. Class 1, embraces those deformities pertaining, in origin or result to:— (1) The Integuments—Burn-cicatrices. (2) Bones—Fracture-union deformity. Rachitis, and Mollities Ossium. (3) Joints—Dislocations unreduced. Diseases of joints with Anchylosis, and Mal-position of the Limb. (4) Musculo-Nervous System. Spinal Curvature—Lateral. Deformities of Face and Neck—Wry-Neck__Squint. Deformities of Arm and Hand—Contractions. Deformities of Leg and Foot—Relaxations and Contractions— Knock-knee—Bow-leg—Club-foot. The first three of these sub-classes are considered in connexion with other Injuries and Diseases ; Deformities as Malformations also are thus associated ;—e.g., with Congenital Dislocations, and, with the pathology of Organs and Regions—Hare-lip, extroversion of the Bladder, &c It remains only to here notice the affections included in the last sub- class (4); associating therewith any remaining Malformations of musculo- nervous origin or character, as that of congenital club-foot. Even in this sub-class, the following Deformity is more conveniently considered elsewhere. Lateral Curvature of the Spine.—See Spine. Deformities of Face and Neck.— Wry-Neck or Torticollis.—This deformity is a twist of the head and neck to one side, in the directions of action of the sterno-mastoid muscle; the head being drawn downwards side- ways, and rotated somewhat outwards. The ear of the affected side may be DEFORMITIES OF FACE AND NECK. 59o draAvn down, so as almost to touch the clavicle. Sometimes the face is turned askew, the features losing their symmetry. The sterno-mastoid muscle is firm, and stands out more prominently, though shortened, as com- pared Avith that on the opposite side. Other muscles apparently become involved, the anterior margin of the trapezius acquiring an outline which defines the posterior boundary of that named triangular space of the side of the neck. The cervical vertebrae slowly undergo lateral curvature; but probably this symptomatic result occurs mostly in Avry-neck connected with disease of those vertebrae. Causes.—Spasmodic contraction of the sterno-mastoid muscle of the affected side, is the most frequent cause of spasmodic Avry-neck. The special accessory nerve Avould seem to be the source of this muscular action, and hence its extension to the trapezius muscle. The spasm is remarkably jerking, painful, and constant, excepting during broken sleep, and it continues for many years ; the sufferer ultimately sinking ex- hausted. This kind of wry-neck usually commences about the age of thirty, and in females, not apparently hysterical, but whose families have an hereditary tendency to other cerebro-spinal affections. Paralysis of one sterno-mastoid is a rare cause of paralytic wry-neck. The head is draAvn to the opposite side by the healthy muscle, not being counteracted by its antagonist. Disease of the cervical vertebra, of scrofulous or rheu- matic character, occasionally gives rise to the deformity. The exciting cause would appear to be, not unfrequently, exposure to cold, or some occasion of local irritation or inflammation of the cervical glands, resulting in stiffness of the neck. Burns of the neck, followed by contraction of the cicatrix, occasion remarkable distortions resembling wry-neck ; but not depending on any affection of the muscles, they are thus distinguished from wry-neck thence arising. Congenital wry-neck is said to be the most common form of this affection. The side of the head, neck, and shoulder Avhich present the deformity, are considerably smaller than the parts on the opposite side; the shoulder and scapula are unduly raised, and the features drawn doAvn and unsymmetrical. The sterno-mastoid muscle is reduced to a narrow, shortened cord, hard and tense. Curvature of the cervical spine has taken place, laterally to the opposite side, and a compensating curve in the opposite direction lower down. Treatment.—Tenotomy or the subcutaneous division of tendons, and muscles, represents a principle of treatment, applicable to a large class of conditions; for the cure or correction of deformities depending on muscular contractions. Stromeyer introduced this principle, in 1831 ; and he Avas folloAved by other surgeons, who have established its remedial efficacy in various branches of Surgical Practice. Division of the sterno-mastoid muscle, subcutaneously.—This procedure affords more or less complete relief of tension, when Avry-neck deformity depends on contraction of the sterno-mastoid muscle. Thus, in spasmodic wry-neck, tenotomy is most successful, and in congenital Avry-neck, less so; while in the paralytic form, and that arising from disease of the cervical vertebra1, this operation will be unnecessary or useless. The muscle should be divided close above the clavicle, the situation of least risk to subjacent parts. By introducing a narrow-bladed tenotome just above the sternum, the sternal attachment of the muscle is divided; and then the clavicular attachment, by repuncturing the integument in that situation. This precaution is safer than division of the muscle by one incision ; as the two portions are not on the same plane, and passage of Q 0 2 596 SPECIAL PATHOLOGY AND SURGERY. the knife to a sufficient depth for that purpose would be dangerous Complete division is accompanied by a Aery sensible crack, and some alteration in the attitude of the head. Immediately after operation, Dr. Little found the difference in length between the affected and sound muscle reduced more than one-half. The advantage gained by the ope- ration, must be followed up by mecha- nical means to maintain and gradually complete the readjustment of the head in position ; otherwise, the divided por- tions of muscle reunite, and the deformity returns. An apparatus invented by Mr. Bigg (Fig. 221) best answers this pur- pose ; by counteracting any tendency of the head downwards, sideways, and out- wards, and thereby restoring it to its vertical position and the chin to the middle line. Dr. Little highly commends cautious manipulation daily, as well as the use of a retentive apparatus. This after-treatment must be continued for a period varying from one to three months, when permanent cures have been accom- plished. Paralytic wry-neck may be rectified by strychnine, electricity, and other measures for the restoration of nervo- muscular action. A steel-spring cravat or other contrivance for supporting the head, is the only mechanical resource available. Disease of the cervical vertebrae, as the cause of wry-neck, can be remedied only by the measures—medicinal, dietetic, and hygienic—appropriate for the particular constitutional condition ; and by wearing a well-adjusted, supporting, and slowly rectifying apparatus. Strabismus or Squint.—A want of parallelism in the axes of the eyes, whenever both are directed to an object at the same time. This habitual mal-position of the eyes results from irregular action of the internal or external rectus muscle; the one producing convergent strabismus—the eye being directed towards the nose; the divergent strabismus—the eye being directed towards the temple. Either form of strabismus may be single; double, when both eyes converge or diverge. The latter direction is rare, and consequent on loss of sight in one eye, Avhich has lasted for years. Causes.—Strabismus may arise from a cause remote in some distant part of the body, of which the squint is symptomatic; or from various local conditions pertaining to the eye ; but more frequently from the former class of causes. Thus, this affection may arise from intestinal irritation or teething; or from disease of, or relating to, the brain, as hydrocephalus. It may be consequent on certain blood conditions, as measles or scarlatina, among the eruptive fevers. Inflammatory, or other diseases, of the eyeball, conjunctiva or eyelids. Extreme shortness of Fig. 221. DEFORMITIES OF ARM AND HAND. 597 sight, compelling the patient to converge both eyes in looking at near objects, may induce strabismus; and it sometimes results from the in- fluence of insensible imitation. Treatment.—Removal of the cause, in any case, will probably restore the regular and equal action of the recti muscles. Hence, any source of irritation in the intestinal canal or elsewhere, should be sought for, and removed, if practicable. Persistent causes render this principle of treat- ment impracticable, and strabismus must then be rectified as an effect, by division of the contracting muscle. This operation, first introduced in 1810, has since been modified. It now consists in swj-conjunctival divi- sion of the muscle affected; commonly the internal rectus. The details of this procedure are described in the chapter on Diseases of the Eye. Deformities of Arm and Hand.—Contraction of the muscles of the upper extremity differs from those of the lower extremity, in so far as the individual muscles of their analogous parts perform functional movements, more delicate, varied, and complex. Various muscles may be affected, producing deformities which correspond to their respective functions. Thus, contraction of the biceps, with permanent flexion of the arm, or the extensors of the forearm, the flexors of the fingers, or those of the wrist, or the pronators; may be severally engaged. As affecting the fingers, muscular contractions produce forms of club-hand. The causes of these contractions, and resulting deformities, are either spasmodic or paralytic conditions; and as depending on some injury or disease affecting the nervous system peripherally or centrally. Treatment must haA'e reference, primarily, to removal of the cause of contraction or paralysis, if possible. But the state of contraction, as an effect, may be overcome mechanically; by manipulations, or by division of the contracted muscle or muscles, or their tendons—the operation of tenotomy; folloAved, in either case, by the use of retentive appliances. The choice of these tAvo procedures will be determined by the kind and degree of motion to be regained in the part, and by the practicability of aiding recovery by means of any apparatus. Thus, according to Dr. Little's experience, the biceps at the bend of the elboAv, the tendons of the flexor carpi radialis and ulnaris close to the wrist, and the pronator radii teres at its muscular portion, have been severally divided in different cases; but the resulting benefit of these procedures has been proportionate to the after-manipulations, passive exercises, and painstaking education of the enfeebled non-contracted ex- tensors. The fingers derive little benefit from any limited degree of the simple movements of flexion and extension, nor can they be assisted by any known form of mechanism. Contraction of the Fingers from disease of the palmar fascia, should be distinguished from contraction of nervo-muscular origin. The patho- logy of this condition Avas discovered, on dissection, by Dupuytren and Goyrand. It results not unfrequently from habitual pressure on the palm of the hand, as in bearing on a knob-headed walking-stick, or using an instru- ment Avhich has this effect, in the exercise of various trades. Or, Avithout any apparent exciting cause, a rheumatic or gouty diathesis may give rise to chronic thickening of the palmar fascia, in the form of projecting ridges extending from the palm to the contracted fingers. (Fig. 222.) The treatment is, in principle, the same; division, subcutaneously, of any tense fascial prolongations binding down the fingers. Sometimes, 598 SPECIAL PATHOLOGY AND SURGERY. Fig. 223. Fig. 222. firm adhesion of the skin to these bands necessitates its separation, by a long incision and dissection of the skin back on either side; the bands must then be divided or dissected off the tendons, leaving their sheaths intact, After either operation, the fingers are to be straightened and letained in position on a splint. Congenital Deformities of the Fingers may be met Avith. Erichsen saAV a case in which the fingers appeared as if they had undergone complete or partial amputation in utero. Some were marked by deep transverse sulci, others shortened and ter- minating in rounded no- dules, Avith a narroAV pedicle attaching them to the proximal phalanx. Supplementary fingers, or a thumb, are also met with. (Fig. 223.) Deformities of Leg. —(1) Knock-knee or In- kuee — Genu Valgum. — This deformity is an imvard yielding of the knee-joint, the result of Aveak- ness of the ligaments and muscles which support the joint in that direc- tion. It occurs not unfrequently, and usually both knees are affected ; giving the person a singularly ungraceful attitude when standing, and in walking the knees knock and roll over each other with a shuffling gait. The causes of knock-knee are apparently mechanical; some occasion of undue strain on the knee. It mostly arises from trying to make a child walk too early, or it may occur in tall, rapidly-growing lads from the age of twelve to eighteen ; in either case the knees yielding under the weight of the body. Habitual over-walking exercise or fatigue in stand- ing, has the same result. Hence certain occupations are causative ; and any habit of resting on one leg, or defect in the opposite limb, whereby an increased strain is thrown upon the sound limb; may induce this de- formity. But, a rachitic tendency, or other constitutional condition of impaired nutrition, can often be traced as the predisposing cause. Treatment.—Removal of the cause in operation, will sometimes prove sufficient. Thus, if the attempt to make a child Avalk at too early a period be discontinued, an incipient knock-knee may disappear. Mechanical support is the only sure means of preventing further de- formity, and of restoring the limb to a proper shape, by allowing the ligamentous structures to gain sufficient strength. The patient must be placed in " irons." An iron stem, on the outside of the limb, extending from the trochanter to the outer ankle, is fixed by a pelvic band above, and into the boot below. A hinge in this rod at the knee alloAvs of motion; while, by means of a leathern pad furnished with straps, applied on the inner side, the joint is secured to the stem above and beloAV the hinge, and drawn outwards by tightening the straps. (Fig. 224.) The knee must thus be fixed during a period varying from three to six DEFORMITIES OF LEG. 599 months; then freedom of motion may be allowed for a part of each day during a similar period ; and lastly, perfect freedom a feAV months before the support is discontinued. The total average duration of treatment, in advanced childhood and bad cases, Avill probably extend to two years. Division of the external lateral ligaments, or of the biceps tendon, has been practised in obstinate cases; but this, or any cutting operation, is not now considered necessary. Constitutional treatment for the improve- ment of nutrition, will aid the mechanical cure. Fig. 224. Fig. 225. Fig. 226. (2) Bowed, or Bandied Legs, present the opposite state of deformity of the Knees. (Fig. 225.) The treatment will consist in a form of appa- ratus to correct eversion of the Knee. The simplest is an inner lateral splint (Fig. '220), as a base opposed to the convexity of the curve. (3) Contraction of Knee-joint.—Unconnected with disease of the joint, resulting in anchylosis with malposition ; simple contraction of the knee is liable to occur. The deformity may be either, flexion of the leg on the thigh, at an angle of various degrees; or, combined with this state, some distortion laterally inwards, with rotation of the tibia outwards. Dis- placement backwards of the head of the tibia, the end of the femur and patella projecting forwards apparently, is associated with rather an ex- tended position of the leg, and laxity of the joint. Fig. 227. The cause of these deformities—apart from joint disease—seems to be 600 SPECIAL PATHOLOGY AND SURGERY. some affection of the ham-string muscles, Avhich induces their contraction, and shortening ultimately. This may be a purely hysterical manifestation, and accompanied Avith other symptoms of the same constitutional disease. Treatment must have reference to the apparent cause of contraction. The more fugitive state of hysterical contraction, may perhaps be over- come under the relaxing influence of chloroform; the limb is then at once Fig. 228. brought down to a straight position, and retained by two lateral splints. (Fig. 227.) Or, reduction is gradually accomplished by a regulated ex- tending apparatus. (Figs. 228, 229.) Division of the ham-string tendons Fig. 229. may be necessary, followed by extension. The biceps and semi-tendinosus ahvays require division ; the semi-membranosus, seldom. This renders the operation more superficial and simple than it would otherwise be. Talipes or Club-foot.—Four forms of club-foot are recognised; talipes equinus or elevation of the heel; talipes varus or inversion of the foot; talipes valgus or eversion of the foot; and talipes calcaneus or de- pression of the heel with elevation of the anterior part of the foot. Varieties of club-foot consist of combinations of two of these forms, the principal of Avhich are; equino-varus, equino-valgus, varo-equinus, cal- caneo-varus, and calcaneo-valgus. (1) Talipes-equinus.—Structural Condition, and Signs.—Certain bones of the tarsus—the astragalus, scaphoid bone, and calcaneum, have under- gone alterations from their normal condition. Diminished in size some- what ; the astragalus, in particular, is reduced, its natural articular surfaces for the tibia and fibula are partially deprived of cartilage, and neAV articular relations have formed posteriorly, more or less in that TALIPES OR CLUB-FOOT. 601 direction according to the degree of the talipes. The calcaneum may even contribute to this new articulation. The head of the astragalus, diminished in size, has an unusually small articular facet in its connexion with the scaphoid bone. This bone also reduced in size but unaltered in shape, is drawn downwards; thus presenting the head of the astragalus prominently on the dorsum of the foot, while a considerable portion ot its upper surface has slid from under the tibia. The calcaneum small, and perhaps articulating with the tibia, has a more limited connexion with the cuboid bone ; and as this bone, with the scaphoid, is drawn down- wards, the anterior and upper portion of the calcaneum also projects for- wards on the dorsum of the foot. The other bones of the foot, somewhat smaller than natural, retain their normal characters ; the remaining tarsal and the metatarsal bones conform to the general curvature—an increased convexity forwards, an increased concavity backwards; but the toes are, usually, extended, horizontally. Thus, then, the heel draAvn up, in this form of talipes, brings the tarsus to nearly a vertical line under the tibia, whereby the Aveight is transmitted to the toes, on Avhich the patient rests in standing or walking. (Fig. 230.) The liga- ments are relaxed and shortened, corresponding to the altered rela- tions of the bones ; which facilitates the progress of the deformity, and impedes restoration of the foot to its natural position. The muscles, however, are the active agents in the production of talipes, one muscle or set of muscles overbalancing another and antagonistic muscle or muscles. In talipes equinus, the gastrocnemius muscle is contracted. This form of talipes is usually single ; but both feet are sometimes * clubbed. Causes.—The disturbed equili- brium of muscular action, in the pro- duction of club-foot, may be spasmodic, Avhen referable to the contracted muscle ; or be due to paralysis of the opponent muscle. Thus, in talipes equinus, spasmodic contraction of the gastrocnemius, may give rise to this deformity; or a paralytic state of the tibialis anticus, or of it and one or more of the other extensors of the foot, be the cause in question. Excit- ing causes comprise various sources of irritation, operating through the nervous system, as teething, intestinal Avorms; or some local irritation, as an inflammatory affection of the muscles of the calf of the leg. Talipes equinus may be acquired or congenital; the latter very rarely, Taniplin, Lonsdale, and other authorities never having seen such a case. Treatment.—Tenotomy is the only mode of cure. Division, sub- cutaneously, of the tendo-Achillis, allows the heel to be brought down; Avhen the foot must be retained in position by a properly constructed extending apparatus. 602 SPECIAL PATHOLOGY AND SURGERY. Fig. 231. Fig. 232. The operation is simple. The patient having been laid prone, the Surgeon grasps the foot and extends it forcibly, thus making the tendon tense and prominent; a tenotomy knife (Fig. 231) is introduced, at either side of the tendon, about an inch above its insertion into the calcaneum; passing beneath the tendon to its opposite side, the knife is withdrawn through the tendon slowly, its fibres yielding with a creaking resistance. The foot at once comes into position, or is readily brought down by ex- tension with the hand, as the tendon is divided. Scarcely more than a drop or two of blood escapes exter- nally, and the puncture is closed by a small piece of plaster. The apparatus for extension is Scarpa's shoe, or its modi- fication by Liston. Liston's Fig. 233. shoe was provided Avith two curved levers. (Fig. 232.) The form of apparatus, or shoe, generally used for talipes equi- nus, is here represented. (Fig. 233.) It consists of a steel splint on the outer side of the leg, with a foot support; both of which are secured by padded belts around the leg and foot. At the connexion of the splint and foot-board, a joint, Avorked by a key, regulates the extension. Stromeyer postponed extension until the puncture-wound had healed; and then applied it gradually. The former rule is now obsolete in practice ; the latter is observed by Little and most authorities. In my own more limited experience I have always employed gradual extension, after teno- tomy. Union of the tendon becomes more perfect, and without entailing any risk of recurring deformity. Walking may be resumed as soon as union has taken place and the movements of the foot are regained, with- out any tendency to relapse ; the period of rest required being, of course, much lessened by wearing the precautionary apparatus above described. (2) Talipes Varus.—The pathology and treatment of this deformity much resembles that of talipes equinus. The structural condition is similar, with regard to the alterations of the bones. But the muscles contracted are principally, the gastrocnemius, with also the tibialis anticus and posticus. The articular alterations, and the accompanying signs, are more like those of equinus, in proportion to the extension and curvature of the foot, which commonly occurs; but the foot is turned inwards, and this is the characteristic distinction. The patient walks on the outer side of the foot. (Fig. 234.) The causes of this deformity would appear to be those of talipes equinus; but the varus form of talipes has been attributed to pressure of the walls of the uterus. It is certainly most frequently congenital; TALIPES OR CLUB-FOOT. 603 almost as exclusively so a3 the equinus form is acquired talipes. Both feet, therefore, are usually affected. Fig. 234. Treatment consists, in subcutaneous division of the tendons of the contracted muscles; the tibial muscles, and the tendo-Achillis; followed by the use of Scarpa's shoe or Aveling's talivert (Fig. 235), to complete Fig. 235. the cure. By the latter apparatus, the three desiderata,—abduction, flexion, and retroversion, are obtained, a, metal shoe-piece; d d, lateral uprights of leg-splint; adjoining fig. b, etc., represents the extending apparatus. In performing the operation of tenotomy, the posterior tibial artery, near the posterior tibial tendon behind the malleolus, is the only vessel liable to be injured; and with it, the companion nerve. This accident has happened in the most experienced hands; a compress and bandage will, mostly, arrest any haemorrhage thence arising. In only one in- stance, has Dr. Little Avitnessed any evil consequence; a small filbert- sized aneurism requiring ligature of the vessel, three weeks after opera- tion. A relapse, or rather conversion of the deformity into the opposite state, sometimes occurs; talipes valgus succeeding. In one case under my care, it Avas necessary to have recourse to the operation for that deformity. The shoe, most frequently used at the Royal Orthopaedic 604 SPECIAL PATHOLOGY AND SURGERY. Fig. 236. Fig. 237. Hospital, is here shown. (Fig. 236.) Dr. Langaard's well-knoAvn in- strument for talipes varus, is also deserving of notice. (Fig. 237.) (3) Talipes Valgus— or in-ankle—presents the opposite arrangement of parts to that of talipes varus, and the peronei muscles are chiefly con- tracted. The foot is turned outwards, and possibly extended up- wards, the patient stand- ing or walking on the inner ankle. Thence also the knee inclines in- wards, combining knock- knee with this form of talipes. Flat or Splay-foot presents the same characters as the above deformity; but, owing to relaxation of the ligaments in the sole of the foot, the arch sinks, and the foot is flattened. The causes of talipes valgus have reference to the contracted muscles, and this deformity may be congenital or acquired. Flat-foot is said to arise, in young persons, from long-continued standing or walking. I have seen it commence in girls who have suddenly become stout and heavy, about the age of puberty; the arch of the foot and inner ankle then giving way. Fig. 238. Fig. 239. The treatment of talipes valgus must be conducted on the principles already laid doAvn in the other forms of club-foot. Tenotomy will generally be necessary; and the tendons to be divided are those of the peronei muscles, and possibly also, of the extensor communis digitorum. The foot is then placed in a Scarpa's shoe. The best form of instrument is that devised by Dr. Langaard, of Hamburgh. (Fig. 238.) It is provided with a tangential ankle-screw TALIPES OR CLUB-FOOT. 605 Slight deformity of this kind can sometimes be corrected by extension, under the influence of chloroform; and subsequently Avearing the shoe. Flat-foot is amenable to the same plan of treatment, with the addi- tion of a convex sole to restore and support the arch of the foot. (4) Talipes-calcaneus.—Marked depression of the heel, and a corre- sponding extension upwards of the foot, characterize this deformity. The plantar arch may be contracted. (Fig. 239.) No structural altera- tions have taken place, but the deformity is simply symptomatic of muscular contraction; the muscles engaged being the four Avhose tendons pass betAveen the two malleoli, anteriorly;—the tibialis anticus, extensor pollicis, extensor longus digitorum, and peroneus tertius, a part of the last-named muscle. The lateral ligaments, in their posterior portions, are much elongated. This form of talipes is very rare, and was first described by Dr. Little, in the case of a child, four and a half years of age. The treatment is much facilitated by the absence of any structural Fig. 240. Fig. 241. impediments. complished by tenotomy ; and the foot is readily retained in position. The best form of instrument, or shoe, for treatment mechanically, in order to restore the normal position and actions of the foot, is that shown in the annexed figure. (Fig. 240.) Bigg's ap- paratus is well adapted for cases of great severity. (Fig. 241.) Varieties of Club-foot.—Combinations of the typical forms of club-foot are liable to occur. They have already been ad- verted to; but, to simplify the descriptions given, it was desirable not to introduce these varieties in connexion Avith their respective types. Reduction can be flexion alone, Fig. 242. easily or aided ac- by 606 SPECIAL PATHOLOGY AND SURGERY. Equino-varus, equino-valgus, varo-equinus, calcaneo-varus, and cal- caneo-valgus, are modifications of the typical forms of club-foot. The particular muscles contracted will be suggested by each of these varieties of deformity. But the muscles engaged are declared by the tension and prominent rigidity of their tendons, as at once discovered by manipu- lative examination of the foot, in the various attitudes it has assumed. Practically, this knowledge guides the appropriate orthopaedic treat- ment ; the manipulative extensions, the operations of tenotomy, and the mechanical appliances. For equino-varus,—to restore the foot to a normal position, Bigg's Orthopede promises to be a valuable instrument. (Fig. 242.) CHAPTER XXXVII. excisional surgery of the joints, and bones. The Joints, for Disease. Excisional Surgery is best introduced by defining its full signification. Excision—or Resection, as it is sometimes less properly called—signifies the removal of any part of the body by a cutting-out operation of extir- pation. This kind of operation relates chiefly to the joints and bones, although it may be practised also for the removal of tumours, as adven- titious growths produced in connexion with the natural organism. The object of excision is, therefore, to preserve or to restore the organism, as far as possible, in or to its healthy anatomical integrity. With regard to the osseous system, comprising the joints and bones, excision may be practised either for disease or for injury of these parts. In approaching this subject we may just take a retrospective glance at its history and time-honoured associations. Hippocrates, in whose writings 2400 years ago so many other surgical aspects of the present age are reflected, distinctly notices the resection of bones at the joints,—as of the leg, the ankle, the forearm, the wrist. Then, again, we find Celsus and Paulus iEgineta both as explicitly directing the excision of the ends of bone,—the one in compound dislocations, the other in compound fractures with protrusion. But the latter writer refers also to the practice of ex- cision for disease of the joints or of the bones : " When," says he, " the extremity of a bone near a joint is diseased it is to be sawn off: and often, if the whole of a bone, such as the ulna, radius, tibia, or the like, be diseased, it is to be taken out entire." Thus, then, excisional surgery had its origin in that fertile period of the world's history when arts and litera- ture flourished. Subsequently, in the course of those dark and dreary middle ages, when the human mind lay dormant, as in a death, it is scarcely possible to trace a vestige of that which was destined to become a leading feature of modern surgery. Not until towards the close of the last century were the operations of joint-excision fully recognised. In 1781, Park, of the Liverpool Hospital, excised the knee-joint, and with a suc- cessful result. This was followed by a second successful operation on the knee, in 1789. Contemporaneously, in France, the Moreaus, senior and junior, practised excision of this joint, between the years 1786 and 1789 : and then of the elbow-joint, the one surgeon in 1794, the other in 1797- EXCISIONAL SURGERY OF THE JOINTS, FOR DISEASE. 607 The efforts of Park and Moreau failed to make any, the slightest, impres- sion on the profession or the public. In September, 1782, Park Avrote to Percival Pott, of St. Bartholomew's Hospital, " a few sheets, in which," said he, " I hope to show that in some of the affections of the knee and elboAv in which amputation has hitherto been deemed indispensably necessary, surgery has yet another resource, which, as far as my reading and experience enable me to judge, has not yet been attempted by any other practitioner—I mean, the total extirpation of the articulation.'1'' He emphasized his suggestion by underscoring it, as an indication for italics. This announcement, however, seemed in no way to have moved the original mind of the famous metropolitan surgeon. On the Continent, the memoirs offered by the Moreaus to the French Academy provoked violent opposition, and were rejected with disdain by the surgical savans of France. Thus it Avas that towards the close of their labours the pioneers of excisional surgery experienced the mortification of knowing that they had attracted no followers—no successors. It is unnecessary to pursue this general historical sketch further; those who revived the operations of excision, and subsequent contributors, Avill be amply noticed in connexion with the consideration of the several joints. Joint Excision in relation to the General Treatment of Joint Disease.— In the pathological history or course of inflammatory joint-affections, certain general indications of Treatment may be recognised, which, in the order of their conservative or preservative character, admit of the follow- ing arrangement; and whereby the relative bearing of Excision, will become apparent. The Vcm-operative indications comprise :— (1) Preservation of the Joint, functionally, by restoration of its mobility. (2) Preservation of the Joint, with loss of its mobility, by Anchylosis. The Operative indications are :— (3) Preservation of the Limb, and Life, by sacrifice of the Joint, Avith anchylosis— Excision. (4) Preservation of the Life alone, by sacrifice of the Limb—Ampu- tation. The question of operative interference, it will thus be seen, can arise only when the joint-disease is already past the control of the first indica- tion of treatment—restoration of the mobility and functional use of the joint; and when it has become subject to the second indication—preser- vation by anchylosis. But this result is also the object of Excision. The true comparison, therefore, of joint-excision for disease, is with the probability of natural cure by anchylosis. Such comparison should have reference, (1) to the joint, in respect to five essential particulars—the ap- propriate nature of the anchylosis or union, and the proper position of the limb for its functional use, the average duration of the periods of reco- very, and the permanent character of that issue, with its average propor- tionate frequency; (2) the liability to life, or the comparative mortality of the natural cure by anchylosis and that resulting from excision, must also be considered. It may seem strange to speak of the mortality of the natural cure, for it might be said, that failing to obtain that issue in due time, the surgeon would interfere by an operation, either of excision or amputation, before death ensues. But the period of natural cure is very protracted, extending often to five years or more, and even to ten years. Cases of this duration respectively—not, it must be confessed, of a very 608 SPECIAL PATHOLOGY AND SURGERY. inviting and encouraging character, are recorded by Mr. T. Bryant and Mr. Hilton, as having occurred in their practice for the mechanical cure of knee-joint disease. But even a more important consideration, is this— that such protracted recovery is attended Avith a proportionate reduction of constitutional vigour. Hence, with reference to the question of mor- tality, operative interference may be too late, or intercurrent disease con- sequent on delay, may carry off the patient; in either case, death ensues from the prolonged attempt to bring about a natural anchylosis. Statistical results, bearing on all these questions, and which shall be sufficiently accurate and comprehensive, are yet wanting to determine the relative value of the two modes of cure—nature versus excision. Mean- while, the fair and reasonable course to take surgically, in any advancing case of inflammatory joint-disease, is ; to try for natural anchylosis by absolute rest and other proper treatment; and failing to obtain that issue, timely excision offers as a subsequent resource, under the conditions which are most favourable for a successful result to this operative pro- cedure. What are they ? By an analysis of twenty carefully recorded typical cases, published in the Medico-Chirurgical Transactions of last year (1870), I endeavoured to establish three propositions, representing the conditions of disease appropriate for excision of the joints in general; and certain supple- mentary propositions relating to particular joints. The experience of eight additional cases enables me to confirm and enlarge these conclusions, and, so far as they may stand the test of further experience, they may be taken as principles or rules for the guidance of the surgeon in his selec- tion of this operation. I may here state that this series of cases is con- secutive—i.e., it comprises all the cases in which I have had recourse to the operation of joint-excision. No adequate basis for generalization can be afforded by any limited series of cases; but my OAvn have the advan- tage of preconsidered observation and analysis specially Avith a view to the purpose proposed; and I have supported my conclusions by large masses of evidence carefully gathered from recorded sources of trustworthy results. General Conditions of Diseased Joints appropriate for Excision. —Functional inutility of a Joint, is the resultant condition -for which the operation of Excision is appropriate; but as this may ensue either from persistent disease, or from failure of the natural cure, of a twofold character, it includes three general conditions, proper for the operation:— Firstly,—as the result of persistent disease—destruction of the arti- cular cartilages, Avith perhaps dislocation, without the supervention of anchylosis; but, whilst the constitutional condition has not advanced to hectic and emaciation. Secondly,—as one result of the natural cure—Anchylosis, of a nature inappropriate to the functional use of the limb ; being ligamentous where osseous union is required, as in the knee; or osseous where ligamentous- connexion is necessary, as in the elbow. Thirdly,—as another result of the natural cure—Anchylosis, with mal-position of the limb. In the event of fibrous anchylosis, Avith mal-position; mechanical extension of the limb, tenotomy, or both these resources may be tried prior to excision of the joint. Certain subordinate conditions, relative to the propriety of Joint- Excision for persistent disease, are less clearly established by an analysis of cases. CONDITIONS OF DISEASED JOINTS APPROPRIATE FOR EXCISION. 609 (1) The comparative eligibility of chronic synovitis or of scrofulous caries, would appear to be in favour of the former disease. Thus, in my knee-joint excisions; of the 12 cases, the 3 Avhich required secondary am- putation were cases of scrofulous caries; of the remaining 9 cases, 6 Avere synovitis, and 3 scrofulous caries. Professor Humphry's experience is someAvhat different—at least Avith regard to the knee-joint—prolonged scrofulous suppuration of the thickened synovial membrane having been the most frequent cause of failure after excision, in his cases. (Medico-Chirurgical Trans., 1869.) (2) A limited extent of osseous disease, would seem to be propor- tionately favourable for excision; but, one or both articular surfaces, or ends of bone, may be diseased. The disease must not extend beyond the limits necessary for the formation of sufficiently wide osseous surfaces for an adequately secure union, osseous or ligamentous according to the functional use of the limb. Or, the limits of diseased bone, Avith relation to excision, may have to be restricted for the preservation of a sufficient length of limb ; and, consequently, for the preservation of the epiphyses or epiphysial cartilages, as affecting the subsequent groAvth of long bones, and thence of the limb. The epiphyses of the tibia and femur, in the knee-joint, for example, in relation to the growth in length of the lower limb, after excision of this joint. (3) Disease of the soft parts around the joint diseased, is not, in itself, unfavourable to the result of excision; even although the integu- ments be much undermined by sinuses, and thickened by gelatinous infiltration, or soddened by puriform discharge. This surrounding con- dition of disease will subside, and the integuments regain a healthy state, when the central source of irritation, the diseased joint, is extirpated ; provided only sufficient sound integument be left to cover the exposed ends of bone. But, advanced integumentary disease is generally con- nected with advanced constitutional disturbance and hectic exhaustion, the most unfavourable condition for joint-excision. (4) A chronic state of disease, in the joint and surrounding soft parts, is a condition of far more favourable character for excision, than one of acute inflammation. (5) In all doubtful cases, as to the diseased condition of the joint; a good practical rule is, to lay the articulation open, by an incision as for the operation, and examine its condition, before having recourse to amputation, which can then be performed at once. (6) Certain co-existing constitutional diseases, as phthisis, seem to have an unfavourable influence, and in proportion to the progress of such disease. (7) Age has no special constitutional relation to the propriety of joint- excision. Either extreme period of life seems unfavourable for this kind of operation, owing to the long period of recovery, averaging three months at least, for the knee or hip-joint; and six Aveeks for the elbow- joint. As to extremes of age ; taking the knee-joint as the best example of a large joint; according to Dr. R. Hodges, excision has been per- formed as early as three years, and as late as sixty-eight years. The former case recovered, Avith Avhat state of after-limb is not recorded ; the latter died. The average age of the fatal cases Avas twenty-five years; of recoveries, nineteen years. Of my OAvn cases, the first, and one of the most successful, was thirty-three years old, and another, equally success- ful, Avas twenty-seven. But, the constitutional power of recoveiy from R R 610 SPECIAL PATHOLOGY AND SURGERY. severe compound fracture, after either of these periods of life, Avould suggest the propriety of trying excisions at a more advanced age. Youth may be unfavourable for the operation, as being subject to an arrested growth of the limb, from removal of the epiphyses or epiphysial carti- lages. But this objection relates only to knee-joint excision, the length of the arm, after operation at the elbow-joint, being comparatively unim- portant ; and even with regard to the lower limb, the line of epiphysial cartilage may not unfrequently be left, thus providing to some extent for the subsequent growth of' the limb in length. Operation of Excision.—Certain general directions are common to all these operations. Instruments.—The requisite Instruments, and Apparatus for after- treatment, are few and of simple construction. They comprise ;—scalpels, thin and stout-bladed, curved copper spatulae, saws—the common ampu- tating saw and Butcher's saw, the chain-saw; gouges, and cutting plier- forceps, the lion-forceps for grasping bone, torsion-forceps, suture- needles, and silk or silver wire; splints and bandages, or other retentive apparatus. This list of armamentaria might be extended, and many and compli- cated instruments are described, particularly by French authors. It would, however, appear doubtful whether some such appliances can pos- sibly be used, in accordance with the design of Excision. Some, indeed, of the above-mentioned instruments are of restricted applicability, and come into use only occasionally. Thus, for joint-excision, the saw devised by Mr. Butcher, has a narrow blade, and being moveable, it can be adjusted at any angle; an advantage for running the saw easily, and in any direction, to finish off the excision. But, for the removal of an accessible slice of bone, the firm bearing of the ordinary broad-bladed amputating saw, is preferable. The chain-saw also will be requisite only under quite exceptional circumstances; as to get round an imbedded bone, and which cannot be exposed and turned out as usual, for appli- cation of the ordinary broad-bladed saw. This is a rare expedient, and I have never had occasion to resort to it, except in excision of the great trochanter; I have seen the chain-saw used in excision of the hip, but not with any apparent advantage ; and once the instrument broke. The " lion-forceps," devised by Sir William Fergusson, enables the operator to gain a firm grip of the off-portion of bone, in order to steady it for the efficient and free working of the saw. This instrument thus proves serviceable in completing the excision of any partially severed portion of bone. Ligatures are scarcely ever necessary for the arrest of haemorrhage; torsion will generally prove sufficient. I have never found it necessary to apply a single ligature in any joint-excision; nor subsequently, but once, on account of secondary haemorrhage. Silver wire is, perhaps, pre- ferable to silk for sutures; the latter material being apparently more apt to induce suppuration, at the points of insertion along the line of incision. (1) The incisions should be formed so as to fairly expose the articular ends of bone. Hence, they vary in shape according to the particular joint; a single linear incision, |, as frequently practised for exposure of the elbow-joint; a double rectangular incision, —|, as also applicable to the same joint; or, as a X shaped incision, to the hip-joint; a curvilinear or elliptical incision, \J, for the shoulder, perhaps the wrist, and the knee; or, an H shaped incision, as some Surgeons prefer for the latter joint; OPERATION OF JOINT-EXCISION. 611 and modifications of these incisions for the ankle-joint. The incisions are so placed as to avoid important parts—tendons, blood-vessels, and nerves; and, therefore, not in the flexure of joints. (2) The ends of bone should not be denuded of their integument or of their periosteum, to any extent beyond the line necessary for the osseous excision ; detachment of vascular connexion predisposing to necrosis. (3) The extent of bone to be removed must be determined by observ- ing the appearances of disease, compared with healthy bone, as discovered during the operation of excision. Hence, this kind of operation may be a piecemeal proceeding; as not unfrequently, in the elbow-joint. But, the results of reparation, in the production of osseous thickening, spicu- lated or nodular enlargement, must not be confounded with the results of disease. In growing long bones—i.e., in young persons, joint-excision should not extend beyond the epiphyses, or at least the epiphysial carti- lages, in the ends of bone, on which the further longitudinal groAvth of the bone—and thence of the limb, depends. The sections of bone should be parallel, so that the opposed osseous surfaces may be adjusted in ap- position ; a rule particularly important when osseous union is required, as in the knee. (4) Skin, and subjacent integument, exclusive of thickened synovial membrane, rarely need be removed; the soft parts recovering a healthy state, and covering from exposure the ends of bone. (5) Hccmorrhage may be arrested by torsion of the arterial vessels; ligature is rarely if ever requisite. Sponging with cold water will arrest any oozing haemorrhage, and wash away any adherent particles of bone, or clots. (6) The ends of bone must be placed in apposition, but not absolute contact—particularly when ligamentous union is required, as in the hip or elbow. (7) The attitude of the limb must have regard to its functional uses, after excision of the joint. Thus, in the loAver extremity, the hip-joint, and the knee, should be straight, for support of the trunk and for pro- gression. In the upper extremity, the elbow-joint should be semi-flexed, to prevent osseous union, and to provide for the relative movements of the forearm and hand. (8) Retentive appliances must have regard to the necessity, or other- Avise, for a fixed position of the limb ; according as the union required is osseous or ligamentous. A suitable splint or splints and bandaging must be applied, so as to prevent the liability of movement, in the directions of displacement peculiar to the joint, after excision ; leaving the operation- Avound accessible for dressing. This principle of treatment will be fully illustrated by the retentive appliances proper for each particular joint. Finally, the line of incision is brought together and closed by sutures of silk or silver Avire; care having been previously taken, at the very last, to see that any clot be Avashed out, and that the ends of bone are in apposition. Strips of lint soaked in water or weak carbolic lotion, are applied to the wound, and overlaid by a large piece of oil-silk; a bandage being applied over all, to further exclude the air, and maintain some com- pression for a time, to prevent oozing secondary haemorrhage. The After-treatment of Joint-Excision, is local, as relating to the pro- cess of union-integumentary, and between the ends of bone ; and consti- tutional treatment, principally hygienic, as relating to the maintenance of r r2 612 SPECIAL PATHOLOGY AND SURGERY. reparative power ; both aspects of the treatment having regard also to occasional complications. (1) Local after-treatment may be reduced to certain rules.—The in- tegumentary wound undergoes more or less tumefaction, but it generally heals by the first intention—primary union taking place along the line of incision; except at its angles, which continue to discharge, slightly per- haps, a puriform matter, or lymph, when the ends of bone have long since united. The first dressing need not be removed, usually for 48 hours ; then, the Avound is to be cleansed, and similar dressing reapplied, the bandage being omitted, or applied lightly as inflammatory SAvelling super- venes. The sutures, some or all, may be alloAved to remain for a week or ten days. The retentive apparatus should not be removed and reapplied for the first month after excision, unless absolutely necessary to correct some important displacement of the ends of bone. If osseous union be required this rule is the more imperative. The splints are reapplied at the end of another month, and so on; about three re-applications only being permitted in the course of osseous union, as of the knee-joint; while the splint may be abandoned, at a more early period, and passive motion commenced, Avhen ligamentous union is required, as in the elbow. A starched bandage may be substituted for splints, when osseous union has become sufficiently firm; and thus enable the patient to get about and regain his general health. Secondary hamorrhage, a rare complication after joint-excision, can generally be arrested by the ice-bag, or irrigation, aided by the compression of a bandage; and I have only once had oc- casion to reopen the wound to secure a bleeding vessel—and that in the knee-joint. Re-excision, and amputation, -will severally be considered in speaking of the different joints. (2) Constitutional after-treatment should be equally free from the imputation of unnecessary interference. Guided by ordinary principles, little medicine-giving will be needed ; the face gradually acquires a re- markable pallidity or sallowness, more than can be accounted for by the comparatively slight loss of blood at the operation; but this appearance wears off, under the influence of quinine and iron with a nourishing diet; the patient—supposing an excision in the lower limb, can often recline on a back-support in bed, so as to be enabled to read or write, or, if a female, amuse herself with needleAvork ; and eventually, before leaving the bed, our patient has become the picture of health. On the other hand, certain constitutional complications are apt to arise after excision, which are of an adverse, or even fatal, character. Prolonged sickness from the influence of chloroform, may be subdued by the hypodermic injection of morphia, in one-sixth of a grain doses, while life is supported by nutritive enemata. Painful jerkings of the limb ; especially in young hysterical subjects, or in consequence of the attrition of the osseous surfaces, is another untoward event, which may be subdued in like manner. Acute inflammatory fever may arise, almost immediately after excision, especially in young subjects; but this sub- sides, or yields to ordinary treatment. Pycemia, I have never yet known to occur after joint-excision. Severe rigors and acceleration of pulse, I have seen arise from attrition of the ends of "bone ; and in consequence of readjusting the splints, a month after excision of the knee-joint. But this paroxysm usually passes off. Tetanus has ensued in only one of my cases,—a knee-joint excision in a young girl 'of sixteen, and with a fatal result; the only death I have yet had after any joint-excision. Exhaus- OPERATION OF JOINT-EXCISION. 613 tion, in consequence of prolonged suppurative discharge, is apt to ensue in scrofulous patients; and this complication will probably lead to re- excision, or amputation instead, or subsequent to this resource. Such cases of secondary amputation are often remarkably successful, in saving life, albeit the limb is sacrificed. Repair after Excision.—Joint-Excision may not be followed by any process of reparation, the ends of bone remaining- ununited, as in un- united fracture. Reparation ensues more commonly, however; and the process consists in the production of a substitute-tissue between the ends of bone, forming an intermediate union; which may be, either fibrous and flexible—as a ligamentous connexion, or an osseous and immovable union. Ligamentous union is accompanied Avith an adaptation of the ends of bone to each other, forming a new joint; as after successful excision of the elbow, an instance of which will be described subse- quently, from a case recorded by Mr. Syme. Osseous union would appear to result from a transformation of the fibrous tissue by a species of ossi- fication ; but associated Avith the production of true cartilage, in the form of nodules, Avhich as centres of development, also undergo ossification. How far the union may become, properly speaking, osseous, attaining to the minute structure of true bone, observations are Avanting to determine. Any remaining portion of the original articular cartilage, after a partial excision, is not continuous with but quite distinct from the newly-pro- duced ossifying cartilage; and the former undergoes fatty and fibrous degeneration, thus losing its cartilaginous appearance. The muscular attachments which had been severed by the osseous excision, probably regain new connexions around the united ends of bone; the tendon of the quadriceps extensor muscle, for instance, acquires an insertion into the end of the femur ; Avhile the soft parts around the joint become more or less thickened and indurated. Thus then, the union is fortified, and the limb adapted to resume its functional use. This description of the process of osseous union accords Avith what Avas found to have taken place after excision of the knee-joint, in one of my cases, Avhich Avas subjected to amputation in St. George's Hospital, ten months after the operation on the joint. The result of examination is given, as " repair after excision," in the Catalogue of the Hospital Museum; and a report also, in the Path. Soc. Trans., vol. xii. But the opportunities for such examination are necessarily few; in most cases, amputation of the limb is resorted to only when no appreciable reparation has commenced. The chief source of reparation is also uncertain. Ollier's observations, Avith those of Maisonneuve, shoAv the importance of the periosteum, as the most acti\*e organ in osseous repair, rather than the bone-tissue or even the medullary membrane, and as being far more productive than the surrounding texture. The same relative im- portance, therefore, may be attributed to the periosteum in the process of repair after excision. Accordingly, I always carefully avoid detaching this membrane, and its vascular continuity Avith the textures around the ends of bone, which should be left embedded up to the surface of section. Excision compared with Amputation.—Amputation of a limb is gene- rally compared with excision of a joint for disease, as if the tAvo Avere alternative operations. Now, the incurability of joint-disease by non- operative treatment is indeed the condition eligible either for excision or for amputation. But in Avhat does such incurability consist ? The whole diversity of opinion and experience among Surgeons in regard to the pro- priety of excision versus amputation springs from a tAvofold vieAV of the 614 SPECIAL PATHOLOGY AND SURGERY. nature of the state in question. Thus, scrofulous disease of the knee- joint may be considered incurable, without operative interference, when the disease has advanced to destruction of the articular cartilaginous surfaces of the tibia and femur without the supervention of anchylosis, so that the joint has become functionally useless; or, the same disease may not be regarded as incurable until it has advanced to a further and even to an extreme state of disorganization—dislocation (partial or complete), abscess, sinuses, profuse and long-continued discharge, with the constitu- tional disturbance of hectic and exhaustion. The turning-point of dis- tinction between these tAvo opposite states of the same disease is this: in the one case the joint has become functionally useless; in the other, to this condition is generally superadded a constitutional state of exhaustion Avhich leaves no period of time nor vital reserve-power sufficient for any prolonged process of reparation after operation—averaging three months for the knee and hip, and six weeks for the elbow. But this measure of time and of reserve-power are the essential ele- ments of that reparative process Avhich will inevitably be necessary to effect osseous or ligamentous union, as the case may be, and thence a successful result after excision. Conseqtiently, compared Avith amputation, the operation of excision, under the adverse circumstances of advanced disease, will be singularly unsuccessful; whilst, at an early period, recourse to amputation is unnecessary and unjustifiable. Excision and amputation for joint-disease are, therefore, not alterna- tive operations for the Surgeon's choice of one or the other. The com- paratively early period for excision is too early for amputation, and the comparatively late period for amputation is too late for excision. When either operation becomes justifiable for joint-disease, the other should not be entertained. The Natural Cure by Anchylosis is the true standard of comparison for joint-excision, which, when successful, also results in Anchylosis ; and such comparison must have reference to the five essential particulars already mentioned (p. 607), and to the mortality. The following general results of excision and their relation to con- ditions of disease of the joints, as illustrated by my own series of cases, may be here noted : 1. Excision proved successful by one operation, in 21 out of 25 cases of the knee, hip, and elbow-joints. 2. Of the 4 unsuccessful cases by one operation, 3 were cases of scrofulous disease, and of the knee-joint in a total of 12 cases; the re- maining I being chronic synovitis, and of the elbow-joint in a total of 5 cases. 3. Re-excision was resorted to in 2 of the 4 cases; 1 knee-joint, and 1 elbow-joint, the latter with a successful result. 4. Secondary amputation in 3 of the 4 cases. All 3 were knee-joint cases, and subjects of scrofulous disease; 1 had been subjected to re- excision. The 3 amputations made rapid recoveries. These results tend to show that if the attempt to preserve a limb by previous excision, and even by re-excision of a large joint as the knee, should fail, the opera- tion is not prejudicial to secondary amputation for the preservation of life. 5. One death only in the 25 cases, of the knee, hip, or elbow- joints, whateA-er had been the condition of disease, subject to the prin- ciples of selection laid down; or whatever the operation; excision, re- excision, or secondary amputation. The fatal case, was after excision of the knee-joint ; and the cause of death,—acute tetanus. CONDITIONS OF KNEE-JOINT DISEASE FOR EXCISION. 615 Special Excisional Surgery of the Joints for Disease.—The Knee-joint.—The Conditions of Disease Appropriate for Excision.—The knee-joint, considered in relation to the operation of excision, illus- trates the three general rules as to the conditions proper for operation :— Destruction of the articular cartilages, and perhaps dislocation (Fig 243), Fig. 243.* FlG. 244.f without the supervention of anchylosis, but whilst the constitutional condition has not advanced to hectic and emaciation; anchylosis of a nature inappropriate to the functional use of the limb—namely, here, ligamentous union; or such anchylosis, coupled with malposition of the limb (Fig. 244) by retraction and dislocation. But there are also certain peculiar conditions as pertaining to the knee-joint which more especially determine the propriety of excision. (1) Compared Avith other joints, a certain limit to the extent of disease is essential to success. The disease must not extend in either the femur or the tibia beyond the limits requisite for the formation of sufficiently wide-based osseous surfaces to permanently support the weight of the body, and for the preservation of a sufficient length of limb to be really useful. The patella should always be removed, as being diseased in some cases, and always useless as a remnant after excision of the joint. (2) In young subjects—under the age of about ten or twelve years— it is of importance that the disease should not extend beyond the limits necessary for the preservation of the epiphyses or of the epiphysial car- tilages ; the integrity of the latter, at least, being requisite for the sub- sequent growth of the bone, and thence of the limb, in length. The observations which led to this rule were originally made by Professor Humphry, of Cambridge. * Case 12 in my Series. t Case 13, uot included in the Series. In these, and all the Cases, the wood-engrav- ings were drawn by Mr. C. DAlton, from photographs. 616 SPECIAL PATHOLOGY AND SURGERY. Operation.—Excision of the knee-joint for disease, originally intro- duced by Filkin, of Northwick, in 1762, was followed by Park, of Liver- pool, as an independent originator, in 1781; but the operation, performed by Syme in 1829, and on the Continent by Heyfelder in 1849, was revived by Sir William Fergusson in 1850, and followed immediately by Jones, of Jersey, and Mackenzie, of Edinburgh. The patient lying recumbent, and under the influence of chloroform, the limb, already bent by retraction of the leg consequent on the joint disease, is firmly held by an assistant so as to present the knee vertically ; his one hand grasping the thigh, the other hand the leg, the foot of which rests on the table. The knee-joint is most conveniently laid open for excision by a curved horseshoe-shaped incision (U)> extending from the side of one condyle downwards Fig. 245. across the head of the tibia, just below its articular surface, to the same point on the side of the opposite condyle. Thus both ends of bone are exposed. A second sweep of the knife, dividing the ligamentum patellae, Avill fairly enter the joint from side to side, when a touch or two over the remains of the crucial and lateral ligaments completely lays it open; the joint being at the same time forcibly flexed by the assistant. (Fig. 245.) In young subjects, with fibrous anchylosis, care must be taken to sever any such union with the knife, lest by forcible flexion either epiphysis become attached—an accident, in regard to the tibial epiphysis, Avhich happened in one of my own cases, and Avhich my friend Mr.Bloxam, of St. Bartholomew's Hospital, has seen occur in two more. The joint having been laid open, I raise the flap of integument with my left hand, hooking my fingers under the patella, and, taking particular care not to detach the integument from the femur, I draw the knife across just above the articular end of bone, so as to define it for excision. The saw, a small, broad-bladed one (Fig. 246), is applied in this line, at aright Fig. 246. angle Lo the bone—observing to make alloAvance for the projecting direction of the articular end—upAvards and forwards, in the flexed position of the limb, as held by the assistant. Unless this direction be observed, the section EXCISION OF THE KNEE-JOINT. 617 of bone will be oblique to the shaft. A few strokes with the saw brings its edge out just behind the condyles of the femur, and corresponding to the posterior margin of the articular surface of the tibia; when a slight jerk outAvards of the blade detaches the section, exposing a broad, flat, osseous surface on the end of the femur. The popliteal vessels and nerves are quite out of the Avay in making this section, the saw inclining forwards almost parallel with them, and the ligamentum posticum intervening. To make the tibial section, I apply the saw similarly in front of the head of the tibia, on the margin of the line of incision about half an inch below the articular surface, no detachment of the integument. being necessary for this purpose, and carry the blade, at a right angle to the bone, or parallel to the articular surface, so as to bring the edge out about half an inch below it posteriorly ; Avhen a jerk upwards Avith the blade Avill detach the articular end without touching the ligamentum posticum, or endangering the popliteal vessels and nerves, and a broad, flat, osseous surface is exposed. Sometimes, the "lion-forceps" (Fig. 247), devised by Sir W. Fig. 247. Fergusson, is a useful instrument for the purpose of grasping firmly and holding steadily either articular section of bone, when nearly detached by the saw. And, this instrument may be equally serviceable in other joint- excisions. If the tibial section Avere made from behind the articular suiface, and the femoral section also, as some Surgeons practise the opera- tion, the popliteal parts would indeed be quite out of the Avay; but the ends of bone are thus apt to be detached from their vascular connexions, and the femoral section, as made from the front, is perfectly free from any risk, while the tibial section can be safely made with the little pre- caution already observed in using the saw towards the posterior ligament. But the liability of wounding the popliteal artery, either with the knife or the saw, should not be overlooked, that accident having happened in at least two instances, one of which was, hoAvever, a re-excision wherein the adjacent parts were somewhat affected by adhesion ; yet, still to in- culcate caution, this accident happened in the hands of a most skilful and practised operator. In the event of such a mishap, amputation must be performed forthwith. Uxcision of the joint may be performed in a block, instead of by separate section, Avhen the articular ends of bone are firmly anchylosed ; the piece of bone cut out having a V shape, owing to the projection of the knee forAvard from constant retraction of the leg. The parallel surfaces of bone, thus made in either way, lie in parallel apposition Avhen the limb is extended. This is the most important opera- tive consideration Avith relation to the formation of firm osseous union. An oblique direction of either surface is most unfavourable to this result; too much suace intervening at one part for the formation of an inter- mediate plate of bone, and the remainder of the surfaces being tightly locked, the limb cannot be flatly extended; painfiil startings of the limb 618 SPECIAL PATHOLOGY AND SURGERY. ensue from attrition of the surfaces in contact, and no intermediate plate of bone can be produced. Thus the union would be in part imperfect or liaginentous, and in part incomplete or wanting. A second section must be made from either end of bone, if necessary, to reach a healthy surface, or gouging may be requisite ; but the extent of bone excised should be limited by the considerations already explained, and the surfaces must always be finished off parallel. The patella is removed, avoiding the making of a button-hole in the integument. Any thickened synovial membrane, often slate-coloured, may be dissected out. Haemorrhage is easily arrested by torsion of the articular arteries, or any other small bleeding vessels. In scrofulous caries little difficulty is experienced. In chronic synovitis the bleeding is sometimes profuse, owing to the vascular and thickened state of the synovial membrane, and the bone remaining healthy and florid. But torsion, sponging with cold water, and exposure, will still prove sufficient to stop the haemorrhage. I then extend the limb, and having seen that the ends of bone lie in even apposition—not absolute contact—a fiat piece of sponge is held on the wound while the splints are applied. The extended limb is laid on a padded back-splint covered with oil-silk under the knee, this splint reaching from the fold of the nates to just above the heel. (Fig. 248.) I now prefer to have the foot-piece part of the lateral splint, as thus the heel escapes pressure and a consequent tendency to sloughing. Mclntyre's splint I have long disused; it not only causes some pressure on the heel, and precludes access to that part for dressing, if requisite, but the trough in which the limb lies induces more wasting of the muscles than would otherwise ensue, and thence also a loosening of the splint at an earlier period than when it may be safely removed for cleansing, and reapplied. Broad strips of adhesive plaster are drawn round the limb and splint, immediately above and below the knee, another broad strip high up on the thigh, and narrow strips around the ankle and instep. A roller bandage is applied from the foot upwards, and another high up from the thigh downwards, leaving the knee un- covered. An outside interrupted splint, well padded, and covered with oil-silk above and below the interruption at the knee, and provided with a vertical foot-piece, is now applied; this splint reaching from above the great trochanter downwards, and the end of the thigh-piece well support- ing the very end of the femur externally, at the seat of excision, while the perpendicular foot-piece maintains the leg in position, and the upper end of the tibia in steady apposition with the femoral end of bone. Elevation of the whole limb five or six inches will be found to further aid the latter purpose. A short padded femoral splint may also be placed in front of the thigh, terminating just above the femoral end of the bone; but if the external thigh-piece be not too wide, this anterior splint will EXCISION OF THE KNEE-JOINT. 619 scarcely be necessary, and I rarely use it. The external splint is secured by a roller bandage from the foot to below the knee, and by another bandage from above the knee, up the thigh, and over the end of the splint, Avith perhaps two or three turns around the pelvis. The use of the external splint is to counteract the tendency to displacement of the lower end of the femur, in three directions, after excision of the knee- joint—projection outwards by abduction, rotation outwards, and projec- tion forwards. The first two displacements give the characteristic bow-legged and twisted appearance which, in a greater or less degree, is so common in the course of union after knee-joint excision, and both of Avhich proceed apparently from muscular action; while the tendency to projection for- wards seems to be produced by a constant sinking of the buttock in bed, thus tilting the loAver end of the femur forwards. The side-splint specially counteracts all three displacements ; the thigh-piece correspond- ing in length and breadth Avith the femur, any tendency outwards is pre- vented ; while eversion and forward projection are restrained by the bandage, and the latter displacement by the support of a firm mattress, or at least a pillow under the buttock. I have had occasion to lengthen this side-splint up to the axilla, so as to counteract a tendency to an angular tAvist of the trunk to the opposite side in bed; whereby the lower end of the thigh is abducted or everted, Avith an angular projection out- Avards at the knee. But there is no tendency to abutment inwards, and no occasion for the application of an internal splint, as practised by some Surgeons. Such a retentive appliance after knee-joint excision is the precaution of a blind timidity, not that which a due knowledge of the possible displacements would suggest. Lastly, the sponge is removed from the excision wound, any clot wiped out, the ends of bone finally seen to be in apposition, and then the flap of integument closed doAvn evenly by points of suture. Strips of lint soaked in carbolic acid lotion (1 part to 40) are laid over the line of incision, and a broad piece of oil-silk OArer the whole knee ; over all a roller bandage is applied to further exclude the air, and maintain some compression to prevent oozing and secondary haemorrhage. The patient is removed to a bed close at hand, the limb elevated on pilloAVS to a height of about six inches, and a cradle placed over the excision. After-treatment should be conducted in accordance Avith the general principles common to all joint-excisions. But I would urge the impor- tance, with reference to the after-treatment of knee-joint excision in particular, of one rule: not to reapply the splints before the end of a month or six weeks, unless absolutely necessary to correct some important displacement. At that time, having removed the splints and gently raised the limb, I sponge it with a spirit-Avash, Avhich both cleanses, and fortifies the skin against the tendency to abrasion from pressure. This must be guarded against in reapplying the apparatus. At the end of another month's interval—the second month—on removing the splints, I gently test the progress of osseous union, by placing my finger over the line of union, and slightly moving the lower end of the leg up and doAvn; the long leverage rendering any degree of movement at the union perceptible to the finger so placed, and even to the eye as a sort of hinge-motion. This test is far more delicate and painless than by grasping the limb above and beloAV the knee, and moving it backwards and forAvards ; how- ever gently that manipulation may be performed. At the end of the third 620 SPECIAL PATHOLOGY AND SURGERY. month, on removing the splints, the trial of union may be made, by seeing whether the patient can himself raise the limb a little from the bed, by its OAvn muscular action. If so, a starched bandage may be applied, pro- vided with a back-splint, and an external splint, of pasteboard; and the limb being slung from the neck by a long loop of roller-bandage, the patient may be allowed to get about on crutches to completely regain his general health. Apertures should be left in the starched bandage, op- posite either end of the incision at the knee, where a small sinus-opening, at both points, often exists; and which may continue to weep for a con- siderable time. Don't probe these little openings. Any necrosed spicu- lum of bone Avill work its Avay out. Any subsequent displacement can be rectified before union is maturely consolidated; and the limb should be very gradually brought into use, for support and progression. Results of Excision of the Knee-joint in relation to Natural Anchylosis. —The true comparison of joint-excision is with the natural cure by anchylosis. Such comparison would involve several essential particulars : the appropriate nature of the anchylosis, and Avith a proper position of the limb for its functional use; the duration of the period of recovery; the permanency of that result, and its frequency, as resulting from ex- cision or from the natural cure ; and their liability to life, or comparative mortality. Statistical results bearing on these questions, and which shall be sufficiently accurate and comprehensive for comparison, are wanting with regard to the knee-joint, no less than in respect to other joints. Six valuable cases of knee-joint anchylosis, resulting from disease, Avithout suppuration, have been recorded by Mr. T. Bryant.* They do not, however, entirely meet the questions which I have suggested, and the limited number of cases do not supply sufficient data for comparison. The period of natural cure would seem to be very protracted, extend- ing often to five years or more, and even to ten years. Cases of this duration, respectively—not, it must be confessed, of a very inviting and encouraging character—are recorded by Mr. T. Bryant, and by Mr. Hilton as having occurred in their practice for the mechanical cure of knee-joint disease. But even a more important consideration is this, that such protracted recovery is attended with a proportionate reduction of constitutional vigour. Hence, with reference to the question of mortality, operative interference may be too late, or intercurrent disease, consequent on delay, may carry off the patient. In either case death ensues from the prolonged attempt to bring about a natural anchylosis. The patient is killed in the curing. But this inquiry must be pursued. Its importance cannot be over- estimated, since, even in the advanced state of suppuration, free incisions into the joint may prove successful in terminating the disease, with a moveable joint, or at least with anchylosis—a mode of treatment in aid of the natural cure for which Surgery is indebted to Mr. Gay. Excision in relation to Life, or the Mortality after Operation.—Taking the results of large collections of cases, those also indifferent Hospitals of the United Kingdom as smaller collections, and from the practice of individual Surgeons as still smaller numbers, three general conclusions may be esta- blished respecting the rate of mortality from knee-joint excision for disease :—1. A diminished mortality as the operation has continued to be practised. 2. Since the revival of the operation, and more recently, an average death-rate of 1 in 4 or 5 cases. 3. Very different death-rates in * Medical Times and Gazette, 1870. RESULTS OF KNEE-JOINT EXCISION. 621 the hands of individual Surgeons, varying from 1 in 2 or 3, to 1 in 12 and 1 in 19, or even less. The conditions of disease, both local and consti- tutional, in the cases selected for operation, have doubtless mainly deter- mined this different resulting mortality, and not uninfluential has been the mode of performing the operation, and more significant the after-treat- ment. But the operation and after-treatment in the particulars essential to success have, perhaps, chiefly affected the resulting state of the limb. The general results respecting the mortality of knee-joint excision for disease in large collections of case3, and those of different Hospitals in the United Kingdom during a period of the last five years, are exhibited in the folloAving collections of cases, which illustrate the three general con- clusions already referred to. For the special returns relating to Hospitals (and to individual Sur- geons), I am indebted to those whose names are stated beloAV. It is scarcely necessary to observe that, of the large total number of cases, some are necessarily included in more than one collection. 1. Collected by Mr. Butcher. Period 1850—54 : Number of cases, 31 : recoveries, 25 ; deaths, 6 (mortality, 1 in 5). Period 1854-56 : Number of cases, 50 : recoveries 41; deaths 9 (mortality. 1 in 5 or 6). 2. Collected by Mr. Price ; period 1760-1860, extended by Mr. H. Smith to 1865.—Number-of cases, 316: recoveries, 240; deaths, 76 (mortality per cent., 24-05, or 1 in 4). Amputations after excision, 39 : recoveries, 30 ; deaths, 9. 3. Collected by Dr. MacCormac.—Number of cases, 74: recoveries, 49; deaths, 25. Amputations after excision, 11: recoveries, 7; deaths, 4. 4. Collected by Mr. W. P. Swain.—Number of cases, 82 : recoveries, 67 ; deaths, 15. Amputations after excision, 4 : recoveries, 4 ; deaths, 0. 5. Collected by Dr. R. Hodges.—Number of cases, 208 : recoveries, 106 ; deaths, 60 (mortality per cent., 28-84, or 1 in 3 or 4). Amputa- tions after excision, 42 : recoveries, 7 (?) ; deaths, 9. 6. Collected by Heyfelder.—Number of cases, 213 : recoveries, 149 ; deaths, 64. 7. Collected by M. L. Peniere (British and foreign); period 1762- 1869.—Number of cases, 431: recoveries, 300; deaths, 131, including 47 amputations and 6 re-excisions. Author'1 s Collection. 1. King's College Hospital; period 1850-70. (Per Mr. H. Smith.) __Number of cases, 80 : recoveries, 57 ; deaths, 23. Amputations after excision, 8 ; recoveries, 4 ; deaths, 4. 2. St. BartholomeAv'sHospital; period 1866-70. (Per Mr. Callender.) .__Number of cases, 37 : recoveries, 2S ; deaths, 9. Amputations after excision, 3 : recoveries, 2 ; 1 death. 3. Royal Infirmary, Edinburgh; period, 1865-9. (Per Mr. P. H. Watson.) Number of cases, 32: recoveries, 18; deaths, 14. 4. St. Thomas's Hospital; period 1866-70. (Per Mr. F. Churchill.) __Number of cases, 22: recoveries, 14; deaths, 4. There Avras one amputation after excision, Avhich resulted in death. (Four cases under treatment.) 5. Royal Free Hospital.—Number of cases, 20: recoveries, 18; deaths, 2. Amputations after excision, 6, of Avhich 3 were re-excisions; recoveries 6. G22 SPECIAL PATHOLOGY AND SURGERY. 6. Chalmers Hospital, Edinburgh; period last six years. (Per Mr. P. H. Watson.)—Number of cases, 18; recoveries, 16 ; deaths, 2. 7. Royal Sea- Bathing Infirmary, Margate; period, last five years. (Per Mr. J. R. Clouting.) Number of cases, 13 ; recoveries, 10 ; deaths, 2 ; re-excisions, 2, no improvement. In 1 case, result not stated. 8. Charing Cross Hospital; period 1870. (Per Mr. Hancock.)— Number of cases 11: recoveries, 11 (?). 9. Royal Infirmary, Liverpool; period last five years. (Per Mr. W. J. Cleaver.)—Number of cases, 11 : recoveries 10; 1 death. Amputa- tions after excision, 3 : recoveries, 3. 10. Westminster Hospital; period last five years. (Per Mr. F. Mason.) —Number of cases, 10 : recoveries, 8 ; deaths, 2. There was one ampu- tation after excision, which recovered. 11. London Hospital; period last five years. (Per Mr. McCarthy.)— Number of cases, 8 : recoveries, 5 ; deaths, 2 ; 1 progressing favourably. 12. Royal Albert Hospital, Devonport; period last five years. (Per Mr. W. P. Swain.)—Number of cases, 6: recoveries, 6. One amputation after excision, ending fatally. 13. Great Northern Hospital; period last five years. (Per Mr. J. Willis.)—Number of cases, 4: recoveries, 2 ; deaths, 2. 14. St. Mary's Hospital; period last five years. (Per Mr. Gascoyen.) —Number of cases, 2 : 1 recovery; 1 death. 15. Guy's Hospital; period 1864-69, or five years. (Per Mr. T. Bryant, from Dr. Steel, Superintendent.)—Amputations after excision, 4 : recoveries, 3 ; 1 death. Comparative Mortality of Excision, and Amputation in the Thigh.— The results of thigh-amputation for disease, as noted in University College Hospital, are thus stated by Mr. Erichsen. Of 34 cases of such amputation, 7 died; or say 1 in 5—a mortality of 20J per cent. Mal- gaigne's statistics from the Parisian Hospitals show a far higher mortality : in 153 cases of thigh-amputation for disease, 92 died, being a mortality of 60 per cent. Mr. Syme represents the mortality as yet higher—from 70 to 80 per cent., taking amputations of the thigh generally. Approach- ing larger masses of results, we find that in Mr. T. Bryant's collection of 1168 cases of thigh-amputation, 254 died, or 217 per cent. ; and in Carrick's still larger collection of 1413 cases, 434 died—a mortality of 30-71 per cent., or 9 per cent, higher mortality than in the former series. These large collections of cases, however, are indiscriminate. They in- clude excisions for injury as well as for disease, and the latter not exclu- sively such as might be eligible for excision. But Mr. Bryant has supplied 188 cases of amputation of the thigh for chronic disease of the knee-joint; and of these there were 41 deaths—1 death in between 4 and 5 cases, or a mortality of 21-8 per cent. This nearly corresponds to the death-rate first stated ; and it about equals the death-rate after excision. But if the mortality of thigh-amputation, and of excision of the knee-joint, both for disease of the joint, be thus about equal, the patients who survive either operation have a very different advantage ; the one being without a limb, the other with the limb preserved. State of the Limb.—The functional result of excision, whether of the knee-joint or other joints, is generally expressed in rather vague terms— e.g., useful limb, without specifying the kind of union, or the position of the limb, as straight or bent. This indefinite mode of record omits much satisfactory information as to the state of the limb after operation. As a RESULTS OF KNEE-JOINT EXCISION. 623 specimen of the average record of results under this head, I may cite from Mr. Butcher's collection of cases referred to in considering the relation of knee-joint excision to the mortality after operation. Of the 25 recoveries, out of 31 cases, 17 were enabled to walk about with "perfect use" of the limb. Of the 41 recoveries, out of 50 cases, 33 had "useful limbs," the remaining 7 being subjected to amputation. Compared with the stump after amputation, Sir William Fergusson justly observes:—" A well-healed stump never in reality improves, un- less, possibly, it gets more callous, Avhilst often it gets more tender and irritable; but the seeming perfect result of excision at the end of six or twelve months, just when stumps are generally at the best, is no criterion of true perfection. If the limb is properly managed afterAvards, it goes on improving for months—ay, for years. The thigh, leg, and foot enlarge in bulk; and in particular, with this change, the leg and foot improve in muscular energy." But why draw any further comparison between a stump—a truncated limb, and a slightly shortened limb, even although the stump be fitted and set off with an artificial leg ? The average duration of the progress of recovery is considerable. According to Dr. Hodges' tables, the duration of treatment, Avhen the pa- tella had been removed, in 48 cases, Avas 225 days; and when that bone is believed to have been left, in 38 cases, this period extended to 255 days. The average duration, therefore, was about eight months. But in S successful cases, all of them children, at St. Thomas's Hospital, the average duration of treatment, as reported by Mr. Allingham, was only 206 days, or about seven months. Many cases also progress more rapidly than this; and in my first case of excision of the knee the period of osseous union was only 60 days, or two months, the knee then supporting the weight of the trunk. This patient was thirty-three years old at the time of opera- tion, with previous synovial disease of six years' duration; and the union has stood the test of twelve years' free use of the limb. The average period for recovery, in my own cases, has been, for the production of firm or perhaps osseous union, three months; and to regain a useful limb, three months more, in a starched bandage, Avith gentle use of the limb gradually, for support and progression. Subsequently the limb will regain bulk and strength by increasing muscular development. The permanent character of a successful result after excision, and the average frequency of such result, are questions severally omitted from sta- tistical records. Both these important elements are noted in the results of my own cases. (See Analysis, p. 629.) The growth of the limb in length, after excision of the knee-joint, is a question respecting which the results are conflicting. The question can only affect the propriety of this operation in youth or childhood. It av.is originally suggested and investigated by Professor Humphry, of Cam- bridge, in an admirable paper on the GroAvth of Bones in their Long Axis at their Epiphysial Cartilages. The two epiphyses—upper and loAver— in a long bone are not equally productive of its longitudinal growth; one is a more active organ of groAvth than the other. In the tibia and hu- merus the upper epiphysis is thus more important; in the femur and radius, the loAver epiphysis. But the loAver femoral epiphysis would appear to be relatively more important to the longitudinal groAvth of the femur than the upper tibial epiphysis is to the elongation of the tibia. Hence, Avith reference to excision of the knee-joint, removal of the femoral epiphysis will more especially arrest the subsequent growth of the 624 SPECIAL PATHOLOGY AND SURGERY. limb in length. The groAvth of the foot also is arrested, so that it may become insufficient to sustain the weight of the body. All this arrest of development may be reduced still further by the imperfect groAvth from previous disease. The practical deduction, therefore, seemed to be, that if, by excision of the knee in a growing subject, the epiphyses and epiphysial cartilages of the tibia and femur be removed, this operation will invariably tend to arrest the growth of the limb subsequently. Mr. Pemberton, of Bir- mingham, followed, in 1859, with a case in which a youth, having been operated on in 1854, the limb in 1859 was nine inches shorter than its fellow. Another case, from the practice of Dr. Keith, of Aberdeen, showed a deficiency in length of five inches during six years' groAvth. Counter-evidence on this question is adduced by Mr. Butcher. Dr. Keith himself wrote to the latter eminent Surgeon, in 1856, that " J. Hay's limb, operated on November, 1853, is plump, and groAving in length as fast as his sound limb. So also is J. Keith's, operated on May, 1854." Corroborative cases are cited from reports by Mr. Page, of Carlisle, and Mr. Brotherston. In a case where the entire epiphyses were removed by Mr. C. Heath from the knee-joint of a boy aged eleven years and a half, subsequent measurements showed that the loss of growth in length of the limb, was only two inches in five years and a half. This case also illustrated the fact that such arrest of growth depends more on the re- moval of the lower epiphysis of the femur than the upper epiphysis of the tibia, the one bone growing in length more than the other after removal of its epiphysis at the knee-joint. Thus, the femur, as compared with its fellow, had lost four inches; the tibia, compared with its fellow, had lost only half an inch,—making an absolute difference in the whole length of the limb of four inches and a half. Still, allowing for these and other exceptional cases, the rule already laid down as to excision of the knee-joint in young subjects, under the age of about ten or twelve years, should be observed. Re-excision.—This proceeding is particularly advocated by Sir William Fergusson. In his " Lectures on the Progress of Surgery" he urges re-excision after a fair trial of the result of the original operation. Then he observes: " I believe dealing freely with the wound, opening sinuses, clearing away strumous effete material, picking away loose necrosed pieces of bone, gouging away bare material of the kind—ay, even open- ing up the whole surfaces, and sawing off fresh pieces of bone, to be better than amputation." My own experience of re-excision, as to the knee-joint, may be thus summarily stated. In 12 cases of knee-joint excision, 1 was followed by re-excision, and 3 by secondary amputation, but with a recovery so rapid as seemed to indicate that neither of the previous operations, excision or re-excision, was prejudicial to secondary amputation for the preservation of life. Secondary Amputation.—The probability of amputation becoming necessary after knee-joint excision is a question that may be determined by reference to the collections of results which I have brought forward, and which show also the mortality thence ensuing, in addition to the pro- portion of deaths arising from the operation of excision. Of the 7 cases alluded to in Mr. Butcher's report as having been subjected to amputation after excision had apparently failed, 6 recovered rapidly, and only 1 died. In my own cases, of 12 knee-joint excisions, 3, including the 1 re-excision case, were submitted to amputation, and all made rapid recoveries. Com- pared with primary amputation of the thigh for disease of the knee-joint, TYPICAL CASES OF KNEE-JOINT EXCISTON. 625 these results as to mortality are most gratifying, and without at once sacri- ficing the limb which might yet be preserved by excision. Thus, in addition to the statistics already quoted, the mortality of primary ampu- tation formerly at St. George's Hospital, as practised for "abscess" and "ulceration of the articular cartilages," was most melancholy. Of 11 such amputations of the thigh at that Hospital, as reported in the Medical Times and Gazette (1856), 5, or nearly 50 per cent., of the patients died, while 1 of the remaining 6 was convalescent only on the sixty-second day. Tvpical Cases of Knee-joint Excision.—In proceeding to record the essential particulars of my own series of knee-joint cases, it seems desirable to take them separately from the records of previous experience, in order to represent this series from tAvo points of view,—firstly, as supplying typical illustrations of the conditions of disease, local and constitutional, Avhich are appropriate for excision, and the results, proximate and permanent, of operation in each case, together Avith any peculiarities ; secondly, the cases are submitted to analysis Avith reference to these, and also any questions of secondary importance pertaining to excision of the knee-joint for disease. Two of the cases were partly narrated in the Hospital Reports of The Lancet of 1860; the remaining ten cases I have abstracted from clinical notes carefully taken by Mr. T. C. Murphy, senior house-surgeon at the Royal Free Hospital. The first four cases especially illustrate the conditions of disease A\rhich I have found to be appropriate for excision of the knee-joint—during the course of disease; in three other cases, 7, 8, and 9, as being failures of the natural cure, both in regard to the kind of anchylosis and by mal- position of the limb. The remaining 5 cases are interesting more par- ticularly as exhibiting peculiarities or complications: in one case, albu- minuria ; in another case, a very early period of life ; in another, preg- nancy at the time of excision, but safe parturition at the full period, Avith a living, healthy child, and the mother's limb having undergone firm osseous union ; in another, accidental detachment of the tibial epiphysis in the operation; in another, acute tetanus and death,—the only fatal case I have yet had after any joint-excision, 28 in number. Cask I.—Elizabeth D-----, set. 33, admitted into the Royal Free Hospital on the 12th of September, 1859. Chronic synovitis of the right knee-joint, of traumatic origin (Fig. 249) ; duration of disease, six years; treatment occasionally. Ulceration of the articular cartilages, and extensive caries of the ends of the femur and tibia. Constitutional con- dition, nervous exhaustion. Excision. Recovery, Avith firm osseous union and a thoroughly useful limb in tAvo months. Result known to be per- manent after ten years. (See Fig. 249.) Case 2.—William A----, aet. 27, admitted into the Hospital, July, 1869. Chronic synovitis of the left knee, apparently of constitutional origin ; five years' duration; four months' treatment. Pulpy thickening of synovial membrane. Ulceration of the articular cartilages, and super- ficial caries of the ends of the femur and tibia. Health good. Excision. Recovery, Avith firm osseous union and a useful limb in three months. Subsequently, limb slightly boAved. Case 3.—John P----, aet. 18, admitted into the Hospital Oct. 19th, 1859. Scrofulous caries of the ends of the femur and the tibia in the right knee-joint, of traumatic origin ; five and a half years' duration ; tAvo years' treatment, in five Metropolitan Hospitals. Partial ulceration of the s s 626 SPECIAL PATHOLOGY AND SURGERY. articular cartilages. Hectic and emaciation ; this constitutional condition improved by medicine and diet, before operation. Excision. Recovery, with union in three months. At another Hospital, apparent recurrence of the disease after ten months. Amputation ; rapid recovery. Fig. 249. Case 4.—Emily R.-----, set. 20, admitted into the Hospital April, 1869. Scrofulous caries of the ends of the femur and the tibia in left knee, of traumatic origin; one year's duration ; nine months' treatment. Ulcera- tion of the articular cartilages. Health irregular. Excision. Recovery, with partly firm union, in three months. Formation of abscesses and sinuses around the callus, and prolonged discharge. Amputation, and recovery in a month. Case 5.—Sarah A. H-----, aet. 18 ; admitted into the Hospital, Feb. 2nd, 1869. Scrofulous caries of the ends of the femur and tibia, in the right knee-joint; of traumatic origin ; twelve years' duration, with occa- sional treatment. Ulceration of the articular cartilages. Marked anaemia. Excision. Secondary haemorrhage next day, suppressed by ice-bag. Dis- placement and projection of the end of the femur on the fifth day. Re- excision of its extremity. Allbuminous urine supervened in a few days, with marked cachexia and prostration; and sloughing of the integument of the calf. A mputation in middle third of the thigh. Rapid disappear- ance of albumen in the urine, and restoration of strength. Recovery by primary union, with a perfectly sound stump in one month. About six months afterwards, stump still sound, but the patient was affected with scrofulous conjunctivitis and opacity of the cornea; also complete deafness. Case 6.—Elizabeth A. G-----, aet. 5 ; admitted into the Hospital, July, 1869. Scrofulous caries of the ends of the femur and tibia, especially the latter, in the left knee-joint of a child ; of supposed traumatic origin; three and a half years' duration, and occasional treatment; ulceration of TYPICAL CASES OF KNEE-JOINT EXCTSION. 627 the articular cartilages. Health good. Excision through the epiphyses. Recovery, with firm osseous union and a useful limb in four months. Case 7.—Henry G-----, aet. 20, admitted into the Hospital, Oct. 28th, 1869. Chronic synovitis of the left knee-joint, of traumatic origin ; one year's duration ; ten months' treatment. Partial ulceration of the articular cartilages of the femur and tibia, followed by partial fibrous anchylosis and retraction of the leg, with partial dislocation of the femur forwards. Health good. Useless tenotomy of the hamstring muscles. Excision. Recovery, with a thoroughly firm osseous union and useful limb in two months and a half. Permanent result, one year. (Fig. 250.) Fig. 250. Fig. 251. Case 8.—Henry II----, aet. 17 ; admitted into the Hospital Nov. 27th, 1869. Scrofulous caries of right knee-joint, of traumatic origin ; fourteen years' duration, with occasional treatment. Partial ulceration of the articular cartilages of the femur and tibia, folloAved by partial fibrous anchylosis and retraction of the leg, with partial dislocation of the femur forwards. Health good. Useless tenotomy of the hamstring muscles. Excision. Recovery, with osseous union and a useful limb in tAvo months. This patient sat up out of bed daily at the end of five Aveeks. Permanent result. Nine months after operation (Dec. 1870) he could stand on the one leg unsupported, and hop on it; just before Christmas he Avalked from near Gray's-inn-road to HarroAV and back —a distance of twenty-four miles—for a day's bird-snaring; and on Boxing-day he Avas sliding on the ice all day. Continued result, one and a quarter year after operation. (Fig. 251.) CAS1.: 9.—Thomas W-----, aet. 10; admitted into the Hospital, Oct. 1869. Scrofulous caries of left knee-joint, of traumatic origin ; seven years' duration and equally prolonged treatment, latterly by extension of the limb. Partial ulceration of the articular cartilages of the femur and tibia, followed by partial fibrous anchylosis and retraction of the leg, with s s 2 628 SPECIAL PATHOLOGY AND SURGERY. partial dislocation of the femur forwards. Health delicate, with constant cough. Excision through the epiphyses. Recovery, with osseous union and a useful limb in two months and a half. Permanent result, one and a quarter year. (Fig. 252.) Fig. 252. Case 10.—Sarah S----, aet. 20. Chronic synovitis of the right knee- joint, of traumatic origin, by a fall off a form. Duration of disease, fourteen years. Treatment in two Metropolitan Hospitals at different periods up to fifteen years of age. At both these institutions amputation of the thigh was declared imperative. Extensive ulceration of the arti- cular cartilages of the femur and tibia; limited fibrous anchylosis, with retraction of the leg to an angle of sixty degrees; anchylosis of the patella to the condyles of the femur. Health reduced; pregnancy of one month. Excision. The night of operation, sickness from chloroform. For two days, painful startings and jumpings in the leg of spasmodic character, affecting the knee. Fourth day, an hysterical fit, and the startings were renewed. The usual apparatus—a long back splint, and an external interrupted splint with foot-piece—holds firmly, and no dis- placement of the ends of bone. Spasms subdued, and sleep induced by the hypodermic injection of morphia—one-sixth-grain doses occasionally. Two months and one week after operation, " quickening " was first felt. The incision was firmly healed by primary union, and firm anchylosis between the ends of bone progressing. Puffy swelling around knee; re- duced by moderate and gradual compression with a many-tailed bandage. On removing the splints, a small ulcer on the heel, and another on the sharp edge of the tibia. Apparatus reapplied, leaving the heel more uncovered, and an opening opposite the tibial ulcer. Under zinc-wash dressings, both sores healed. General health very good ; the patient fast regaining flesh and colour, with a bright eye and cheerful aspect—looking, indeed, the picture of health. Recovery, with firm fibrous anchylosis, in TYPICAL CASES OF KNEE-JOINT EXCISION. 629 three months ; limb put up in a starched bandage, and the patient allowed to get about on crutches. Shortly after, was discharged from the Hospital. A tendency to bowing outwards of the knee was soon evinced; rectified by gradual manipulation, the imperfectly ossified callus admitting of such readjustment, and the starched bandage reapplied. Parturition at the full period; the mother and child both having done well. Firm osseous union. Permanent result, six months. Case 11.—Harriet M----, aet. 16. Chronic synovitis of the left knee- joint, of traumatic origin,—by a fall, and many years afterwards, by a puncture-wound with a crochet-needle two inches in depth, penetrating the joint. Duration of disease, thirteen years from first injury, six months from the second. Treatment commenced three years ago, con- tinued for one year in a Metropolitan Hospital, then for some time in a special Hospital—where extension Avas long used without any permanent benefit. Partial ulceration of the articular cartilages of the femur and tibia ; limited fibrous anchylosis, with retraction of the leg—the toes just touching the ground, and partial dislocation of the femur forwards. Ex- cision. Sickness after chloroform. Acute inflammatory fever in twenty- four hours. Slight rigors on each of the two days following the opera- tion. Third day, copious pink lithates deposit in urine, and subsidence of the fever. Sixth day, slight return of feverishness, and in the even- ing, erythematous patches appeared on the arms, front of chest, and neck, face flushed. This subsided in tAventy-four hours, under treatment by bicarbonate of potash and tincture of hyoscyamus. Eleventh day, a gan- grenous patch of skin, about the size of half-a-crown, in the middle line of the incision, which sloughed away in two days, exposing a portion of the femoral end of bone. All the sutures were now removed. Wound otherAvise healthy, primary union taking place except in middle, and, as usual, at the angles. Ends of bone in perfect apposition. Sixteenth day, trismus, followed by full development of tetanus in tAventy-four hours. At the end of thirty-six hours, death. Hydrate of chloral had been tried in ten-grain doses, every hour. P.-M. Examination of the joint— Union by tags of lymph, puriform fluid around ends of bone. Case 12. — William B-----, aet. 9. Chronic synovitis of the left knee-joint, of traumatic origin, by a slight blow with a hoop. Duration of disease, ten months. Treatment in two Metropolitan Hospitals ; and then in the Royal Free Hospital—by strapping, tic. Discharged ; re- admitted in a month; extension by a back splint and screw, continued for five Aveeks Avithout any effect. Partial ulceration of the articular carti- lages of the femur and tibia; fibrous anchylosis, with retraction of the leg—the toes touching the ground, and partial dislocation of the femur forAvards and outwards. Excision. Accidental detachment of tibial epiphysis, its removal, with the articular end of the femur through its epiphysis ; also the patella. Recovery Avithout a bad symptom. Result— Period since operation, five months. Analysis of the Cases.—(1) Conditions of Disease.—Caries in all cases, Avith the destruction of the articular cartilages of both the femur and tibia. In Case 1 the femur was chiefly affected, in Case 6 the tibia, and in the other ten cases both bones were about equally affected. Thf patella Avas healthy in nearly all cases. (2) Commencement of the disease.—Synovitis in six cases—1, 2, 7, 10, 11, 12- scrofulous caries in the other six cases. Cause: Traumatic in eleven cases ; constitutional in Case 2. 630 SPECIAL PATHOLOGY AND SURGERY. (3) Duration of disease, and of treatment previous to operation.—Case 1 : disease 6 years; treatment occasionally. Case 2 : disease 5 years; four months' treatment. Case 3 : disease 5| years; 2 years' treatment. Case 4 : disease 1 year ; 9 months' treatment. Case 5 : disease 12 years; occasional treatment. Case 6 : disease 3| years; occasional treatment. Case 7: disease 1 year; 10 months' treatment. Case 8: disease 14 years ; treatment occasionally. Case 9 : disease 7 years; and equally prolonged treatment. Case 10: disease 14 years; treatment in tAvo Metropolitan Hospitals. Case 11 : disease 13 years; treatment 1 year in a Metropolitan Hospital, then in a special Hospital. Case 12 : disease 10 months; treatment in two Metropolitan Hospitals, then in the Royal Free Hospital. (4) The constitutional disorder had not advanced to hectic and emacia- tion in any of the tAvelve cases except in Case 3. In Case 1, nervous exhaustion; 2, health good; 4, health irregular, digestion impaired; 5, marked anaemia ; 6, health good; 7, health good; 8, health good; 9, health delicate with constant cough; 10, health reduced; 11, health good ; 12, health good. Pregnancy, without miscarriage, at the time of excision; parturition at the full period, mother and child well; in Case 10. (5) Age and sex.—Age: 33, 27, 18, 20, 18, 5, 20, 17, 10, 20, 16, and 9 years. Sex : six males and six females. (6) Operation.—The incision Avas semilunar downwards from condyle to condyle in all the cases. The portions of bone excised were the articular ends of the femur and tibia in all the cases, with additional portions of cancellated bone in Cases 1 and 6. The patella was removed in all cases. The synovial membrane was also removed as much as pos- sible in cases 2 and 7 of chronic synovitis. Hmnorrhage was inconsider- able during the operation in all the cases, no ligatures Avere required, the articular vessels being secured by torsion and exposure. Sutures—metal- lic in Case 1, silk in the subsequent eight cases. Dressings—water dress- ing in Cases 1 and 3, Aveak carbolic lotion in the other ten cases. Splints —a Mclntyre, or else a back splint with foot-piece in all the nine cases, with an outside interrupted splint in all cases except 1 and 3. (7) Primary union.—Complete, except just at angles of the incision, in Cases 2, 6, 7, 8, 9, 10, 12, or in seven cases ; partial in Cases 1, 3, 4, 5, 11, or in five cases. Secondary haemorrhage in Cases 3, 5, and 8; arrested by ice in the first case, by ligature in the latter two. Sloughing or ulceration from pressure in tAvo cases, 5 and 10. (8) Intervals of removal of splints.—Average period one month after operation, and at similar periods subsequently; making only three or four reapplications of the retentive apparatus in each case. (9) Results.—Osseous or firm union, and a straight limb, in all the cases; except Case 3, where it was incomplete; Cases 4 and 5, which were subjected to amputation; and Case 11, the only death, and from acute tetanus in thirty-six hours, seventeen days after operation. Period of union, average three months. Subsequently the limb slightly bowed in two cases—2 and 6 ; the latter a child aged five. (10) Re-excision in Case 5—a scrofulous case. (11) Secondary amputation in Cases 4 and 5—both scrofulous cases; also in the questionable Case 3—a scrofulous case. (12) Permanent result.—Ultimate known period: (1) 11 years; (2) CONDITIONS OF HIP-JOINT DISEASE FOR EXOlSloX. 631 Hyear; (6) l^year; (7) 1 year ; (8) llyear; (9) H year ; (10) 6 months; (12) 5 months. Such, then, at present, is the recorded contribution of the Royal Free Hospital to excisional surgery of the knee-joint for disease. Hip-joint.—The natural cure of hip-joint disease has not yet been investigated in a series of cases, sufficiently accurate and comprehensive, for comparison with the results of excision. Such an inquiry should have regard, (1) to the joint, in respect to five essential particulars—the appro- priate nature of the anchylosis, and the proper position of the limb for its functional use, the average duration of the period of recovery, and the permanent character of that issue, with its average frequency; (2) the liability to life or the mortality of the natural cure. It Avould be from these points of view, as to limb and life, that the results of excision must be compared and its relative value estimated. Pending this clinical inquiry, we may approach the question from our present knoAvledge of pathology. What, then, are the changes Avhich the joint and constitution undergo in the course of natural cure by anchylosis ? In the joint there is a two- fold process of destruction and reparation. A piecemeal or molecular excision, so to speak, is constantly progressing, apparently by absorption and certainly by the draining aAvay of debris of bone in the discharge until tAvo healthy opposed surfaces are reached, so that union may at length be effected. This natural cure of joint-disease entails a protracted period of recovery, extending even to many years as compared with that of weeks or months required for recovery after excision. During this ordeal the constitutional vigour is reduced, subsequently leaving the patient stamped with the aspect of suffering in former years. Occurring also as it often does during the growing period of life, the reserve poAver, Avhich should have been gained to meet the exigencies of after-life, is used up prematurely by incessant demand in the long process of reparative anchylosis. Persons who have undergone the natural cure of diseased hip-joint, for example, may be seen hobbling about the streets, being easily recognised by the characteristic gait of old-standing hip disease, and by their sallow and prematurely aged appearance. This constitutional decrepitude may possibly be averted by a remarkable acceleration of the excisional part of the process. In a case represented by specimen No. 7 of the hip-joint series, an eminent Surgeon differed with myself and others respecting its diagnosis ; nature subsequently undertook the opera- tion of excision en masse, for she severed and discharged the greater portion of the head of the femur through one of the fistulous tracks. This natural excision of a joint—one of the only tAvo, I believe, on record— Avill be singularly suggestive to operative excisionists, and it should be equally admonitory to those Surgeons Avho blindly oppose the operation. The Conditions of flip-joint Disease Appropriate for Excision.—It Avas formerly held, and may still be maintained by some Surgeons, that Excision of the hip-joint for disease should be resorted to only in the folloAving conditions—constitutional and local: — (1) Only in the last stage of the disease, or of constitutional endu- (2) Only Avhen the extent of disease is limited, the acetabulum being free from disease, and the amount of pelvic disease trivial. (3) Only Avhen the head of the femur is dislocated. The reverse of these rules or nearly so may be partly gathered from 632 SPECIAL PATHOLOGY AND SURGERY. my cases, and can, I believe, be justified by accumulated experience, drawn from the results of a large but varying number of cases, Avith regard to each such rule in question. Of the three conditions laid down respecting Excision of the Joints in general, the first only applies to the hip-joint. (1) Destruction of the articular cartilages, without the supervention of anchylosis, will always justify operative interference by excision. The constitutional condition Avill probably not then have advanced to hectic and emaciation. (Fig. 253.) But the state of the general health should primarily determine the necessity for excision in all cases, and not any arbitrary consideration of the period of the disease and the condition of the joint. Whenever, therefore, the general health is manifestly failing, whatever may be the stage of the hip-joint disease, excision should be resorted to and without further delay. This guiding rule was strongly urged and clearly illustrated by Mr. Hancock in his recent lectures at the Royal College of Surgeons. On the other hand, the most extreme state of constitutional exhavistion, previous to the operation of excision, may be folloAved by recovery after removal of the diseased bone ; as the successful results in my OAvn series of hip-joint cases, 1, 2, 4, and 6, clearly show. (2) Osseous anchylosis with mal-position of the limb Avill not justify the peril of attempted excision. Section of the neck of the femur is practicable, whereby the limb can be brought down to a straight position. This principle of operation Avas lately practised in a case by Mr. W. Adams, and successfully. (3) The extent of bone diseased may be considerable, and involve both the femur and acetabulum. In the femur the diseased portion may include the head, neck, great trochanter, and shaft, entering even into the medullary canal. In the acetabulum the diseased portion may include the whole floor of this cavity, and even extend to adjoining portions of the ilium, pubis, and ischium. Neither of these conditions of extensive osseous disease prohibits excision; but the acetabulum not unfrequently recovers itself when the diseased head of the femur has been removed from further contact and attrition. (4) Dislocation is unfavourable for excision, as implying an advanced stage of the disease constitutionally. The significance of this local con- CONDITIONS OF HIP-JOINT DISEASE FOR EXCISION. 633 dition will, therefore, diminish in proportion to the absence of marked hectic and emaciation. The evidence in support of these principles or rules for hip-joint ex- cision is important, seeing that they are at variance, as I have said, with the results of former experience. Firstly, respecting the constitutional condition. Advanced hectic, in- evitably consequent on prolonged irritation and suppurative discharge in the last stage of the disease, will evidently have so reduced or exhausted the patient's reserve-power, as to peril the prospect of recovery, although the diseased bone be then removed by excision. The deliberate post- ponement of the operation until that period when constitutional exhaustion Avith emaciation is verging on dissolution, would be almost equivalent to operating on a corpse. By analogy, I Avould liken it to the postponement of operation for the relief of strangulated hernia until the patient is sink- ing in consequence ; the Surgeon deliberately alloAving the expenditure of the reserve-power requisite for recovery, without which operative inter- ference must necessarily be a failure and the patient doomed. Hey's maxim respecting strangulated hernia is at least suggestive with regard to excision :—" I have often had occasion to regret operating too late, I have never regretted operating too early." It is no answer to this argu- ment for timely operation as the rule, to point to exceptional cases of suc- cessful results at a later period, in the obviously adverse condition of constitutional exhaustion. Osseous anchylosis of the hip-joint, with useless mal-position of the limb, would seem to invite excision, to restore a straight limb and with a moveable joint; but the difficulty of detaching the firmly soldered femoral head from the acetabulum, or the damage done by this procedure, would be such as to render the operation impracticable or fatal. Section of the femur, between the trochanters, or in the neck, has been proposed and practised instead; operative procedures of which I shall have to speak in due time. Respecting the extent of bone which may be excised successfully, this element in the operation of hip-joint excision does not appear among the tabulated particulars of the majority of cases recorded. The portions of bone removed in each of my own cases are stated in the analysis of the series. As to the femur, in one case, I excised four and a half inches of the bone,—namely, head, neck, great trochanter, and two inches of the shaft, Avith about one inch more of the cancellated bone below, thence entering the medullary canal. That is, I believe, the largest femoral portion of bone Avhich has hitherto been removed in any case of hip-joint excision on record. The patient recovered, with a thoroughly useful limb, and permanent result at the end of five years. Sir W. Fergusson removed four inches of the femur in one case. The acetabulum is very rarely the seat of origin in hip-joint disease, yet that portion of the articulation rarely remains unaffected. Of 92 cases, referred to by Mr. Hancock, in only 18 the acetabulum was healthy. But the head of the femur is mostly diseased in a greater degree, it haA-ing been entirely absorbed in 10 cases out of 143. In these 143 cases, also, the acetabulum was found more or less diseased in 119. In 10 cases an opening in the floor of the acetabulum communicated with the interior of the pelvis. In 4 cases perforation had taken place, and abscess Avithin the pelvis. In 3 cases the acetabulum was trephined for the evacuation of pelvic abscess. Reparation may ensue in the diseased acetabulum, 634 SPECIAL PATHOLOGY AND SURGERY. when the head of the femur is removed from contact and attrition ; as attested by the results of cases of dislocation consequent on disease, which in so advanced a condition must have involved the acetabulum. Or, the disease may progress to perforation, followed by pelvic abscess, and a fatal termination. The fair inference is, that excision will be rendered more safe by removing any diseased portion, or even the whole floor, of the cavity. Thus, the acetabular, and even the pelvic portions of bone removed, with success, have varied considerably in size. In 1 case Sir W. Fergusson removed nearly the whole of the acetabular cavity. In another case, Mr. Hancock removed the whole of the floor of the aceta- bulum, and the head of the femur. The patient recovered. In 1 case, Sayer, of New York, removed the acetabular cavity, with the spine and anterior crest of the ilium, as well as the head of the femur. The patient recovered. In another case, Mr. Bowman gouged the acetabulum, and the horizontal ramus of the pubes. The patient recovered. Lastly, Mr. Erichsen removed not only the whole floor of the acetabulum, but also the rami of the pubis and ischium, with part of the tuberosity of the ischium, and a portion of the dorsum ilii. The patient recovered. In my OAvn cases, I have never had occasion to remove more than small portions of the acetabulum, which were scooped out in each case; the adjoining portion of the horizontal ramus of the pubes Avas denuded in one case, but it was left untouched and underwent repair. As a rule, I find, that superficial caries of any adjoining portion of pelvic bone is best left alone; rather than by groping about in the dark with a gouge, the vascular continuity of the integuments should be detached, and perhaps a portion of the carious surface may still be left unscraped. Nature, subse- quently, completes the excision by molecular disintegration and discharge from the pelvic surface; Avith some prolongation only of the period of recovery, but with greater safety to the patient. Lastly, dislocation is unfaArourable, as implying an almost necessarily advanced stage of the disease constitutionally. Of 123 cases, more or less advanced to exhaustion, in 44 only, the head of the femur yet remained in the acetabulum. Operation.—Excision of the hip-joint was originally proposed by White, of Manchester, in 1769, but the operation was first performed by Schmalz, of Pirnie, Saxony, in 1816 ; and first performed in this country, and for the second time in Europe, by Anthony White of the Westminster Hospital, in 1821 ; it was repeated by Hewson of Dublin, 1823 ; after which period the operation fell into disuse, until its revival by Sir William Fergusson, in 1845. Since that period it has been performed by many Surgeons, and in a large number of cases. The hip-joint deeply placed, owing to the neck of the femur, is reached most conveniently by a T shaped incision; the vertical line, perhaps slightly curved, being made from just above the great trochanter downwards on the shaft to about three inches or less in extent (see Fig. 253), and the transverse line about half that extent on the summit of the longitudinal in- cision. The very limited extent of this latter incision avoids the femoral vessels anteriorly, and the crural nerve posteriorly. In disease of the joint, with perhaps consequent dislocation backwards on the dorsum ilii, and Avasting as the result of long-standing disease, these incisions seem to be almost invited, so prominently does the trochanteric portion of the femur abut under the integument. By detaching the integument on either side of the vertical incision, keeping the knife turned towards the EXCISION OF THE HIP-JOINT. 635 femur especially on its inner side, the subjacent portion of femoral shaft is exposed; then, sinking the knife vertically in the transverse incision, just above the trochanter, the attachment of muscles thereto is divided; so that the finger can be readily passed down to the joint and its state ascertained. The capsular ligament will generally have given way or en- tirely disappeared. To turn out the remnant head of the femur for excision, it may be necessary to adduct and evert the limb, when with a touch of the knife on the bone, the round ligament yields and the head starts from its socket. Or, this ligament also may have disappeared, and the head and neck of the femur be so reduced, and the acetabulum so patulous, from more ad- vanced disease, that the bone can be readily dislodged and hooked out with the finger. In a third class of cases, dislocation back- wards has taken place. In any case, how- ever, adduction of the limb across the op- posite thigh presents the bone for applica- tion of the saw; and then the diseased portion is removed by one or more succes- sive slices, the integument on either side being protected by a curved spatula. (Fig. 254.) The chain-saAv may be used by those who prefer it. A gouge may be used to finish off the femoral excision; instead of unnecessarily removing any healthy portion of the trochanter, if that be left, or of the adjoining shaft. The acetabulum should be scraped rather than gouged, to remove any carious or denuded portion; or, more extensive pelvic excision may be necessary, and has proved successful. But superficial caries, aceta- bular or pelvic, will often recover itself, the former having been main- tained by constant attrition of the femoral head. Any haemorrhage is easily arrested by torsion. I have never had occasion to apply a single ligature in any hip-joint excision. The limb can now be brought down straight, and a long interrupted- splint applied. Or, at first, the limb may be placed in an easy position on a pilloAV, and in the course of a few days, a long splint applied during the formation of flexible union. Or, guided by the pathological fact that this kind of union is required for the successful result of hip-joint ex- cision, I have not used a splint from first to last, in any of my own cases. The healthy section end of the femur becomes draAvn up, if dislocation has not already taken place, and the bone hitches on a healthy surface just out of the remnant acetabulum, Avhere a sound fibrous anchylosis or false-joint is formed. Excision of the trochanter major may occasionally prove sufficient; caries of this portion of the femur existing, Avithout disease of the hip- joint. I have had one such case, and Avith a successful result. The after-treatment of excision, Avhether of the hip-joint, or of the great trochanter alone, is very simple. The limb may be laid straight in bed, and retained in position only by a small side pillow, or roller sand-bag ; Avithout absolutely fixing the thigh. Or a long splint may be applied, extension being made from the opposite thigh, as recommended by Sir W. Fergusson. (Fig. 2ob.) Of these tAvo modes of after-treat- 636 SPECIAL PATHOLOGY AND SURGERY. ment I prefer the former, especially for the joint-operation. The section- end of the femur is drawn up by muscular action, and hitches just above the acetabulum, which having been, generally, more or less superficially carious, is thus left to recover itself, undisturbed by any attrition of the femoral end of bone; while a new, and firmly fibrous, moveable joint forms, where the end of bone rests above the acetabulum. There is little, or no, tendency to displacement after hip-joint excision, and the slight extra shortening which results from thus leaving the limb to itself, is unimportant compared Avith the advantages in regard to the acetabulum, and the formation of the best kind of new-joint requisite for the functional use of the limb, in progression, as well as for support. All my cases were treated in this way, and with perfect success. Results.— (1) In relation to life or mortality. In 111 cases, collected by Dr. Hodges, of unrecorded conditions of operation; 56 recovered, 53 died from the combined effects of the operation and the previous disease ; and in the remaining 2 cases, amputation was resorted to. Thus about 1 in 2 died,—a very high mortality. But Mr. Hancock presents the following A'ery interesting results as to the mortality Avith reference to certain guiding conditions of disease for operation:—The acetabulum in a healthy state, gave a mortality of 6 in 18 cases, or 33 per cent. On the other hand, acetabular disease has had more favourable results of opera- tion. Of the 10 cases in which perforation had taken place, 6, or 60 per cent., recovered; 2 only, or 20 per cent., died. Of the 4, in which not only perforation existed, but abscess also within the pelvis; 2 reco- vered, 2 died,—50 per cent, either way. Of the 3 in which the aceta- bulum was trephined for the evacuation of matter from the pelvis; 2, or 66 per cent., recovered; l,or 33 per cent., died. Therefore, in the Avhole 20 of these apparently most unfavourable cases for excision, the morta- lity Avas only 5, 1 in 4, or 25 per cent. The relation of pelvic disease to mortality after operation, has already been noticed. Dislocation of the head of the femur having taken place ; the percentage of recoveries was actually 46, against 23 where it had remained in its socket; the total number of cases compared being 143. Of my own 8 cases of hip- joint excision ; in 4 there was dislocation, and they all recovered equally with the four in which dislocation had not occurred. Another equally large series of cases—112, British and Foreign, has been collected by Dr. R. R. Good, late Surgeon in the Confederate American Army. This series is the more complete, as it embraces the most essential particulars respecting Excision of the hip-joint for disease, both in regard to its Mortality, and the state of the limb. We are thus enabled to take a commanding view of* the Avhole subject; and in order RESULTS OF HIP-JOINT EXCISION, 637 to observe the results, and their relationship more clearly, I have tabulated them. Tabular view of 112 cases of Hip-joint-Excision, British and Foreign; Period 1860-8. Mortality. Collection of Cases by Dr. R. R. Good. (1) Number of cases, 112. (2) Recoveries, 52, or 46-43 per cent. Deaths, 60, or 53-57 „ Causes.—Exhaustion, 22. Phthisis, and progress of the dis- ease, 10. Pyaemia, 5, Caries of the pelvis and purulent discharge, 4. Diarrhoea, 3. Exhaustion, with rapid pulmonary congestion, 2. Tubercular meningitis, tetanus, diphtheria, Amyloid degenera- tion of the organs, diffuse phlebitis of the limb, osteo-myelitis, haemorrhage, acute necrosis of the femur, nervous collapse and pneumonia, each 1. (3) Disease, recorded in 29 cases. Scrofula, 3; 2 deaths, or 6667. Cold, 4; 1 death, or 25-00. Injury, 20; 4 deaths, or 20.00. (2 cases not included.) (4) Duration previous to operation, recorded in 58 cases. Average duration, 2 years 3 months. In acute cases, or before 7 months; of 9 cases, 7 deaths or 77'77. In chronic cases, or 2 years and more; of 30 cases, 10 deaths, or 33-33; a balance in favour of chronic disease, 44'45. (5) Age, in the 52 recoveries; average, 11 years; extremes, Avere 2 ,, years and 58 years. in the 60 deaths; average, 14 years; extremes, were 3 ,, years and 40 years. from 2 to 12 years, 59 cases; 24 deaths, or 40-67. ,, 12 to 20 years, 25 cases; 15 deaths, or 60-00. „ 20 to 58 years, 17 cases; 13 deaths, or 76'47. (6) Sex. 79 males. 30 females. (3 sex unrecorded.) (7) Bone excised, recorded in 105 cases. a Femur ; section above great trochanter in 49 cases, 30 deaths, or 61*23. Section below great trochanter in 56 cases, 27 deaths, or 4821. A balance in favour of section below,— 13-01 b Acetabulum—Diseased in 72 cases, or 64-28. Deaths, 39, or 54.16. Abscess of pelvis, recorded in 6 cases; 2 deaths. Perforation in 11 cases (of the 72); 6 deaths, or 54-55. Perforated surgically in 5 cases (of the 72); 1 death, or80'00. Gouged in 33 cases; 15 deaths, or 45'45. No interference in 6 cases; 5 deaths, or 83-33. —Healthy in 14 cases. Deaths 7, or 50-00. As compared with the mortality of diseased condition, 54-16; a balance of only 4*16 in favour of healthy condition. Dislocation, recorded in 17 cases; 6 deaths, or 35-29. As compared with non-dislocation in 93 cases; 52 deaths, or 55*92. A balance of 20-63 in favour of Dislocation. 638 SPECIAL PATHOLOGY AND SURGERY. Countries. Cases. Deaths. Germany 34 22, or 64-71 England 32 11, or 34-37 America 29 13, or 44-83 France 14 12, or 85-71 Russia 3 2. 112 Author's Collection. (1) Charing Cross Hospital; period, 1862-70. (Per Mr. Hancock.) Number of cases, 15 ; recoveries, 13 ; deaths, 2. (2) Royal Free Hospital; period, 1863-70. Number of cases, 11 ; recoveries, 10 ; deaths, 1. (3) King's College Hospital; period, last five years. (Per House- Surgeon.) Number of cases, 10 ; recoveries, 9 ; deaths, 1, six months after operation from tubercular meningitis. (4) London Hospital; period, last five years. (Per Mr. J. McCarthy.) Number of cases, 10 ; recoveries, 4 ; deaths, 5 ; 1 progressing favourably. (5) St. Thomas's Hospital; period, 1866-70. (Per Mr. F. Churchill.) Number of cases, 8; recoveries, 1; deaths, 5; 2 under treatment. (6) Westminster Hospital; period, last five years. (Per Mr. F. Mason.) Number of cases, 6 ; recoveries, 6. (7) Guy's Hospital; period, 1864-69. (Per Mr. T. Bryant, from Dr. Steel, Superintendent.) Number of cases, 6 ; recoveries, 5; deaths, 1. (8) Liverpool Royal Infirmary; period, last five years. (Per Mr. W. J. Cleaver.) Number of cases, 4 ; recoveries, 3 ; deaths, 1. (9) Great Northern Hospital; period, last five years. (Per Mr. J. Willis.) Number of cases, 3; recoveries, 3. (10) Chalmers Hospital, Edinburgh ; period, last six years. (Per Mr. P. H. Watson.) Number of cases, 3 ; recoveries, 1; deaths, 2. (11) St. Mary's Hospital; period, last five years. (Per Mr. Gas- coy en.) Number of cases, 2 ; recoveries, 2. (12) Royal Albert Hospital, Devonport; period, last five years. (Per Mr. W. P. Swain.) Number of cases, 2; deaths, 2. (13) Royal Sea Bathing Infirmary, Margate; period, last five years. (Per Mr. J. R. Clouting.) Number of cases, 1; deaths, 1. (14) Royal Infirmary, Edinburgh ; period, 1865-69. (Per Mr. P. H. Watson.) Number of cases, 1 ; deaths, 1. (15) St. Bartholomew's Hospital; period, 1866-70. (Per Mr. Cal- lender.) No cases. Taking the results of the preceding collections of cases, three general conclusions may be established respecting the rate of mortality from Hip-joint excision, for disease:—(1) In different countries, a very dif- ferent mortality, being highest in France, and lowest in England. (2) An average death-rate, of 1 in 4 or 5 (about the same as that of knee- joint excision, for disease). (3) Very different death-rates in the hands of individual Surgeons, British and Foreign—varying from, no mortality, to 1 in 2 or 3, 1 in 5, 2 in 3, 4 in 5, or even total mortality; thus dif- fering far more extremely than the mortality of knee-joint excision for disease. It can scarcely be doubted that the conditions of disease, both local and constitutional, in the cases selected for excision, have mainly determined this different resulting mortality; although, the mode of per- forming the operation, and the after-treatment, have also been influential. RESULTS OF HIP-JOINT EXCISION. 639 Mortality compared with hip-joint Amputation.—In 42 cases of ampu- tation at the hip-joint for chronic disease; 24 recovered, and 18 died,— a mortality nearly as high as 1 in 2. It Avill be observed that the total number of cases here referred to is small, in proportion to the number of hip-joint excisions for disease. But the whole number of hip-joint amputations, hitherto published, is only about 126,—including the cases of injury and disease. (2) State of the Limb.—In Dr. Hodges' collection of 111 cases, the 56 recovered " with more or less useful limbs." In Dr. Good's collection of 112 cases, of the 52 recoveries, 42 patients could use the limb, and in the remaining 10 cases, this residt was not noted. The 42 cases are divided as folloAV :— 19 could walk without support. 9 >) Avith the help of a stick. 1 >■ ,, two sticks. 1 D ,, a splint 1 >> ,, a crutch. 2 >■ ,, two crutches, 9 the manner of Avalking is not specified. In 40 of the 52 recoveries, it was specially noted that the limb sup- ported the weight of the body. In one case, crutches Avere necessary for this purpose, and in the remaining 11 cases, this particular Avas not noted. The movements in the new joint were reproduced in 28 cases, and in only 1 immovable anchylosis was the result. The ultimate period Avhen the patients were seen after operation, varied from three months to five years. Their cure was ascertained, in most cases, after two or three years. Of the 52 cured, the average period of known permanent result, was nineteen months and four days. In my own 8 cases, the shortest period of known permanent cure Avas two and a half years ; and the longest ascertained result, five years. The average duration of the period of recovery has not generally been noted in the records of cases. In Dr. Hodges' collection of forty-nine cases wherein this particular Avas observed, the average AAras 230 days. In my OAvn cases, the average period of union was three months. In extreme cases of hip-joint excision—extreme as to the extent of bone removed—the resulting state of the limb may yet be successful. It was so in my own two such cases, after removal of the upper end of the femur, to four inches and four and a half in length, with one inch more of cancellated bone, and entering the medullary canal, in both cases ; and, also in both the cases of acetabular and pelvic bone-disease, after removal of the affected portions of bone by Mr. Hancock and Mr. Erichsen respec- tively,—the patients recovering, and with useful limbs. Section, rather than Excision, of the upper end of the femur, is a pro- cedure Avhich has been devised, and practised in a few instances, for failure of the natural cure,—osseous, instead of ligamentous, anchylosis of the joint, Avith useless mal-position of the limb, as by flexure on the thigh and abduction. This condition, calling for operative interference, is com- partively rare. Section of the femur has been performed, either between the trochanters, or in the neck, about its middle, and with successful results. The one line of section was originally proposed and performed by Dr. Rhea Barton, of Philadelphia, in 1826. A crucial incision Avas made over 610 SPECIAL PATHOLOGY AND SURGERY. the great trochanter, seven inches in length and five inches in the hori- zontal direction ; a fine saw was introduced, the femur divided trans- versely between the trochanters, and the limb brought down. The result was successful; an artificial moveable joint formed : but seven years after- wards, anchylosis ensued, and two years subsequently, the man died of phthisis, nine years after the operation. A similar operation in situation —between the trochanters, but an excision of a transverse plate of bone, of an elliptical form upwards, by means of the chain-saw, was performed by Dr. Louis Sayre, of New York, in two cases, both in the year 1862. The object of this procedure was to form a false joint, of a ball-and- socket character. The first case was completely successful at the end of six months, the patient, aged twenty-six, being able to stand on either leg Avithout crutch or cane; and upwards of five years afterwards the result Avas permanent: the man could move and Avalk with practical agility. In the second case, the operation Avas followed by abscess and necrosis; but the patient, a female aged tAventy-four, died, apparently of tubercular pneumonia. Post-mortem examination showed that an artificial joint had formed; the articular surfaces were tipped with cartilage and provided with a synovial membrane, and there Avas a complete capsular ligament. Subcutaneous section, and higher up, in the neck of the femur, Avas first proposed and practised, by Mr, William Adams, in December, 1869. The object of this procedure was to procure an artificial, moveable joint; that result having failed, osseous anchy- losis, but with the limb in a straight posi- tion, was sought to be established, and obtained. A long tenotomy-knife Avas entered a little above the great trochanter, and passed down to the neck, the capsular ligament was opened freely, and the neck of bone divided by a narrow, fine saAV, applied from before backAvards. (Fig. 256.) The tendons of the long head of the rectus, the adductor longus, and tensor vaginae femoris muscles, Avere then di- vided ; the limb Avas brought down straight, and fixed by a long interrupted Liston's splint. Five months after this operation, and subsequent treatment, the man, aged twenty-four, Avas exhibited at the Medical Society of London, where he walked about the room without any assistance—a success ful result Avhich has since become perma- nently secured. The annexed figures repre- sent the appearances of the limb, before and after operation ; in the latter, the patient standing on the limb, to shoAV the restored usefulness of the member. (Figs. 257, 258.) This operative procedure has since been practised successfully in three other cases—by Mr. T. R. Jessop, of Leeds; Mr F. W. Jowers, of Brigh- ton ; and Mr. Furneaux Jordan, of Birmingham. The fact of four conse- cutively-successful cases having occurred, goes so far to establish subcu- taneous section of the neck of the femur as a surgical procedure for osseous anchylosis of the hip-joint with mal-position of the limb. I may noAv give a summary of my own series of hip-joint cases ; as TYPICAL CASES OF HIP-JOINT EXCISION. 641 affording typical illustrations of the conditions of disease which are appro- priate for excision, and the results, proximate and permanent, in each case ; an analysis being appended, with reference to the several questions of importance pertaining to excision of the hip-joint for disease. Fig. 257. Fig. 253. I have drawn up these cases from clinical notes carefully taken—in the first two by Mr. John B. Foster, in the second two, by Mr. Marriott, formerly House Surgeons; and in the remaining four, by Mr. T. C. Murphy, Senior House Surgeon, at the Royal Free Hospital. Typical Casks of Hip-joint Excision.—Case 1.—William M-----, aet. 26. Admitted into the Royal Free Hospital, March 28th, 1864. Scrofulous caries of the left femur; the head and the articular car- tilage entirely destroyed, the neck, great trochanter, and one inch of shaft involved, with one inch more of cancellated structure; similar disease of acetabulum, and horizontal ramus of pubes; dislocation on dorsum ilii with abscess; constitutional condition, advanced hectic; disease of traumatic origin; duration of disease, four years; treat- ment, three years. Excision of four inches of femur, and one inch of cancellated structure. Recovery, with a freely moveable joint and a useful limb, in three months. Permanent result known after two years and a half. Case 2.—John R----, aet. 16. Admitted into the Hospital, July 22nd, 1863. Caries of left femur; its neck and great trochanter, the head involved, with circumferential destruction of the articular cartilage, and disease in the shaft to two inches in extent, with one inch more of cancellated structure; similar disease of acetabulum; dislocation on dorsum ilii with abscess; constitutional condition, advanced hectic; immediate cause, cold ; duration of disease, one year. Excision of four T T 612 SPECIAL PATHOLOGY AND SURGERY. inches and a half of femur, and the one inch of cancellated structure. Recovery, with a freely moveable joint, and a useful limb, in tAvo months and a half. Result known to be permanent after five years. Case 3.----George C----, aet. 15. Admitted into the Hospital, June 9th, 1864. Caries of right femur; its head and neck entirely destroyed ; great trochanter and a small piece of the shaft involved ; similar disease of acetabulum; dislocation and abscess on dorsum ilii; health good; disease of traumatic origin; duration of disease, two years. Excision of one inch and three-quarters of femur. Recovery, Avith a freely moveable joint and a useful limb, in three months. Case 4.—Edward M----, aet. 8. Admitted into the Hospital, June 10th, 1864. Caries of left femur, its head and neck destroyed; similar disease of acetabulum ; advanced hectic ; immediate cause, cold ; dura- tion of disease, five years. Excision of two inches of femur. Recovery, with a moveable joint and useful limb, in two months. Case 5.—Jane L----, aet. 5. Admitted into the Hospital, March 4th, 1867. Caries of right femur, its head and neck destroyed ; similar disease of acetabulum ; health good ; of traumatic origin ; three years' duration, two and a half years' treatment. Excision below great trochanter. Recovery, with a moveable joint and useful limb, in four months. Result known to be permanent after three years. Case 6.—Catherine R-----, aet. 5. Admitted into the Hospital, Octo- ber 31st, 1866. Scrofulous caries of left femur, its head and neck des- troyed ; similar disease of acetabulum ; dislocation and abscess on dorsum ilii; advanced hectic ; disease apparently of traumatic origin ; one year and eight months' duration, and treatment. Excision below great trochanter. Recovery, with a moveable joint and useful limb, in three months. For the particulars of this case I am indebted to my colleague, Mr. John D. Hill, then Senior House Surgeon in the Hospital. In two other cases, the essential particulars were similar to one or other of the above series. Analysis of the Cases.—The following facts respecting the foregoing cases of hip-joint disease and excision seem specially worthy of notice. (1) Conditions of Disease.—Caries in all cases, with destruction of the femoral articular cartilage, entirely in 1, 3, 4, 5, 6, or in five cases; cir- cumferentially only in Case 2. Extent of bone diseased was the head, and neck in each case; with the great trochanter and portion of the shaft in Cases 1, 2, 3; and an extra portion of cancellated structure of the shaft in Cases 1 and 2; caries of the acetabulum to some extent in all cases, and of ramus of pubes in Case 1; dislocation on dorsum ilii in Cases 1, 2, 3, 6 ; or in four out of the six cases. (2) Immediate Cause.—Injury in Cases 1, 3, 5, 6 ; cold in 2, 4. (3) Constitutional Condition.—Advanced hectic in Cases 1, 2, 4, 6, or in four of the six cases ; health good in Cases 3 and 5. (4) Previous Duration of Disease.—Four years, one year, two years, five years, three years, one year and eight months. Previous duration of treatment.—Case 1, three years; Case 5, two and a half years; Case 6, one year and eight months. (5) Age and Sex.—Age : 26, 16, 5, 8, 5, 5 years. Sex: four males and two females. (6) Operation.—Incision X-snaPe(I in all cases. Portions of bone excised: (1) Four inches of femur, and one inch of cancellated structure scooped out; (2) Four inches and a half of femur, and one inch of can- cellated structure scooped out. In both these cases the medullary canal CONDITIONS OF ANKLE-JOINT DISEASE FOR EXCISION. 643 was entered ; (3) One inch and three-quarters of femur ; (4) Two inches of femur ; (5) Section just below great trochanter; (6) Section just below great trochanter. Small portions of the acetabulum Avere scooped out in each case. Haemorrhage inconsiderable in all the cases. No ligatures required. Silk sutures and Avater-dressing applied in all the cases. No splint Avas used in any of the cases, the section of the femur being left free to form a fibrous anchylosis. (7) Primary union ensued in all the cases, except the first, Avherein the wound healed by granulation. (8) Results.—Firm fibrous anchylosis, Avith a moveable joint and useful limb in all the cases. Period of union, average three months. (9) Result known to be permanent in Case 1, after tAvo and a half years; in Case 2, after five years; in Case 5, after three years. Ankle-joixt.—The operation of excision with regard to the ankle- joint has been confusedly described in Surgical Avorks as signifying the removal of any portion of the foot, Avhether pertaining to the ankle-joint or not; in the operations originated by Liston, Wakley, and Teale. But, by excision of the ankle-joint, I mean the removal of the articular sur- faces of the bones Avhich enter into the formation of this joint—namely, the lower articular ends of the tibia and fibula, and the upper portion of the astragalus. This operation, first performed for injury by Hippocrates, and revived by Hey, of Leeds, in 1766, Avas first performed for disease by Moreau, senior, in 1792 ; then by Moreau, junior, in 1796 ; next by Mulder, in 1810; and probably by Champion, in 1813. But the credit of introduc- ing the operation into British Surgery is due to Mr. Hancock, Avho excised the ankle-joint for disease in February, 1851. The operation has since been resorted to by Professor Humphry, of Cambridge, in four cases, and by other Surgeons, including myself. The Conditions of Ankle-joint Disease Appropriate for Excision.—Dis- ease of the ankle-joint, according to Mr. Hancock, frequently commences in the synovial membrane, and extends to the articular surfaces; thus, secondarily, involving the bones. But it may also commence, as scrofu- lous disease, in the cancellous tissue of the long bones—tibia and fibula, or of the astragalus, or of all three bones. In the former condition, the affected portion of the articular surfaces may be removed Avith safety and advantage. In th elatter condition, excision is not inappropriate. Other and different opinions are held by some Surgeons of repute, as by Mr. Furneaux Jordan, of Birmingham, both Avith regard to the origin of disease of the ankle-joint, and the propriety of excision. That disease rarely extends from the synovial membrane, but begins in the cancellous tissue, either of the extremities of the tibia and fibula, or in that of the astragalus; and, it is said, necessarily affects the Avhole of that bone. In the one condition, excision of the extremities of the long bones, as the local source of the disease, is said to be inadmissible; while, in the other condition, the whole bone—astragalus, must be excised. The former contra-injunction is plainly at variance with the established practice of excision in disease of the knee-joint, under strictly analogous circum- stances__Avhen the end of the femur, or head of the tibia, is the seat of disease. Excision of the extremity of either of these long bones is not inadmissible, but only, perhaps, less favourable in scrofulous disease of the cancellous tissue. The fair inferences from this diversity of opinion respecting the TT 2 644 SPECIAL PATHOLOGY AND SURGERY. diseased conditions of the ankle-joint for which excision is appropriate, would appear to be :— (1) When disease commencing in the synovial membrane, has ox.- tended to and destroyed the articular surfaces of the tibia and fibula, that of the astragalus, or of both opposed surfaces. (2) When disease, having the same articular consequences, commenced in the cancellated tissue, either of the long bones, or of the astragalus, provided it be limited to part of this bone, its upper articular portion. (3) Whether the disease originated in the synovial membrane or in the articular cancellated tissue, resulting in destruction of the cartilages, without anchylosis ; excision should be resorted to before the supervention of constitutional exhaustion. Operation.—Hancock's description of excision of the Ankle-joint, as first performed by him in England (1851), is as follows :—" I commenced an incision behind, and about two inches above, the external malleolus, carrying it forwards beneath that process across the front of the joint, and terminating about two inches above and behind the inner malleolus. This incision included the skin, without implicating the tendons or their sheaths. The flap thus formed was dissected up, and the peronei tendons were detached from the groove behind the fibula and cut through, as were the external lateral ligaments close to the fibula, with a pair of bone-nippers. I next divided the fibula about an inch and a half above its inferior extremity, and cutting through the inferior tibio-fibular liga- ments, detached the external malleolus. Turning the leg on to its outer side, I cut through the internal lateral ligament, carefully keeping the knife close to the end of the tibia, to avoid the posterior tibial artery. The tendons of the tibialis posticus and flexor communis were then detached from the groove behind the internal malleolus, and taking the foot in both hands, Mr. Avery holding the leg, I dislocated the foot out- wards, thus bringing the end of the tibia with the internal malleolus prominently through the wound. These were removed by a common amputating saAV, applied half an inch above the horizontal articulating surface of the tibia, the soft parts being protected by a spatula ; the upper articulating surface of the astragalus was also removed by a meta- carpal saw, held horizontally. The foot was then restored to its proper position, the cut surface of the astragalus being adapted to the cut surface of the tibia; and the wound having been closed by sutures, except on the outer side, left open for the free escape of discharge, the leg was placed on an external splint, having an opening corresponding to the Avound." The parts divided by this operation were—the skin, peronei tendons, internal and external, lateral and inferior tibio-fibular ligaments, and the articular surfaces of the bones. In subsequent operations, the tendons Avere preserved entire. In no instance have the tibial arteries, anterior or posterior, been wounded, and never has it been necessary to apply a single ligature. Lateral incisions alone, without the anterior communication, have since sufficed. This Avas my mode of operation in two cases. The After-treatment of ankle-joint excision should be conducted in accordance with the principles laid down respecting the excision of other joints ; regard being had to the kind of anchylosis necessary for the use of the limb. The fixed position of the foot must be maintained during the period requisite to secure a firm anchylosis of the osseous surfaces made by excision—the lower ends of the tibia and fibula, and the upper sur- RESULTS OF ANKLE-JOINT EXCISION. 615 face of the astragalus ; thus to adapt the foot for support and progression. The wounds, one on either side of the ankle, are dressed from day to day ; but the splint should be removed and reapplied very seldom. In my own excisions of the ankle-joint, I have fixed the leg on a flat back- splint, provided with a foot-piece ; thus secured, displacement can scarcely occur, and the side wounds are freely accessible for cleansing and dressing. Eventually, a starched bandage may be applied; and the foot being slung from the neck, the patient gets about on crutches, as the foot is gradually brought into use. Results.—Excision of the Ankle-joint, for disease, presents some most interesting results, both in relation to the mortality of this operation, and the state of the foot, with the probability of secondary amputation; both these aspects of the operation being considered also as compared with amputation of the leg, and with Syme's and Pirogoff's operations of amputation at the Ankle-joint, severally for disease. Lor certain valuable statistics bearing on these important questions, I am indebted to Mr. Hancock, who liberally placed at my disposal the manuscript of his Lectures at the Royal College of Surgeons. (1) In relation to Mortality.—The results of 32 cases of excision of the ankle-joint for disease have been collected by Mr. Hancock ; all that he could find recorded in the practice of British Surgeons. Of these 32 cases, 7 died—about 1 in 5, or a fraction above 21 per cent. But of the 7 deaths, 4 are reported to have died of consumption, 1 suffering from that disease at the time of operation; while another died of secondary syphilis. This reduces the average mortality to 1 in 16, or about 6 per cent. Of my own tAvo cases, both lived. Author's Collection. (1) Charing Cross Hospital; period, 1858-65. (Per Mr. Hancock.) Number of cases, 6; recoveries, 6; amputation after excision, 1; re- coveries, 1. (2) Royal Free Hospital; period, last five years. Number of cases, 4 ; recoveries, 4 ; amputations after excision—Sjnne's amputation, 1; re- coveries, 1. (3) Chalmers Hospital, Edinburgh; period, last six years. (Per Mr. P. II. Watson.) Number of cases, 4 ; recoveries, 4. (1) Royal Infirmary, Edinburgh; period, 1865-69. (Per Mr. P. H. Watson.) Number of cases, 3 ; recoveries, 2 ; deaths, 1. (5) St. BartholomeAv's Hospital; period, 1866-70. (Per Mr. Cal- leuder.) Number of cases, 1; recoveries, 1. (6) St. Thomas's Hospital; period, 1866-70. (Per Mr. F. Churchill.) Number of eases, 1 ; deaths, 1. (7) London Hospital; period, last five years. (Per Mr. J. McCarthy.) Number of cases, 1 ; recoveries, 1; amputations after excision, 1 ; recoveries, 1. Guy's, King's College, Westminster, St. Mary's, and Great Northern Hospitals, Liverpool Royal Infirmary, Royal Albert Hospital, Devon- port, and Royal JSea-Bathing Infirmary, Margate; period, each last five years. No cases. Compared with the Mortality of Amputation.—(a) in the leg; (b) at the ankle-joint—Syme's and Pirogoff's amputations of the foot. (a) Amputation of the leg. for disease, in Civil Surgery, has a mortality of 26 percent. ; Avhereas, in the results of ankle-joint excision for disease, 646 SPECIAL PATHOLOGY AND SURGERY. the mortality, already quoted, has been only 6 per cent.; 20 per cent. difference in favour of excision (b) Amputation at Ankle-joint—Syme's Amputation.—Of the whole number of Ankle-joint amputations—219, as collected by Mr. Hancock, in 144 amputation was performed for disease—caries. Of these, 10 only were fatal, or somewhat less than 1 in 14; and as 3 died of phthisis, 1 of diarrhoea, and 1 a year after operation, 5 deaths only remain; or a reduced mortality of 1 in 28. Pirogoff's Amputation.—Fifty-eight cases of this amputation represent the whole number, performed by British Surgeons, of which Mr. Hancock has been able to gather the particulars. Nearly 100 cases reported by Pirogoff as having been performed in Russia, are not available for statistical comparison. Of the 58 cases, 5 were fatal, or about 9^ per cent. Of the remaining 53 recoveries, in 29 the operation had been resorted to for caries. (2) State of the Foot.—Of the 32 cases operated on by excision of the ankle-joint, 21 recovered with good useful limbs. Secondary amputation, after Ankle-joint excision.—Of the 32 cases, 2 only underwent secondary amputation, and both recovered. Compared with Secondary amputations, after amputations of Foot.— (a) After Syme's operation; of the 144 cases submitted for caries, 9 underwent secondary amputation; but of these, 1 was a confirmed drunkard, 1 had been primarily operated on for traumatic gangrene, 1 two years previously for an accident, and in the remaining 2, the disease is not stated, (b) After Pirogoff's operation, of the whole 58 (for disease and injury) 5 only suffered secondary amputation, but in 4 of these the primary operation had been performed for caries. Comparing these two amputations of the foot, Mr. Hancock ob- serves ; as regards the occurrence of suppuration, the percentage of deaths, of recoveries and periods of recovery, and secondary amputations; the evidence of British Surgery is in favour of Syme's operation, whilst as regards sloughing of the flap, it is decidedly in favour of Pirogoff's proceeding. Syme's amputation appears to be unquestionably the best for disease, and Pirogoff's for the accidents of civil life, since by it we preserve an increased length of limb. Tarsal Bones.—Excision of the Tarsal Bones comprises certain recog- nised operative procedures, which correspond to the lines of the osseous articulations; as removal of the astragalus, or of the os calcis. But the plan and performance of excisional operations on the foot should not be restricted by these anatomical limitations. The modification of these operations on the foot, according to the kind and extent of the disease, well illustrates the guiding principle of excisional surgery; and this application of the general principle I have laid down, is specially advo- cated by Mr. Hancock, in the Lectures already referred to. The conditions of disease for which excisional operations on the foot may become appropriate, are similar to those which affect other bones and their articulations; namely, the destructive results of inflammation, and especially in the form of caries. According to the extent of such disease, partial or complete excision of any one, or more, tarsal bones may be necessary. I proceed to describe the various operations, and to estimate their value by their results. (1) Excision of Astragalus.—Partial excision of the astragalus, for disease, Avas first attempted by Severin in 1616, and in England by Ram- say in 1792. Since that time it has been performed by other Surgeons, but in a comjiaratively feAv authentic cases. EXCISION OF THE TARSAL BONES. 647 Complete Excision.—This operation, as for disease, was first performed by Mr. Busk in 1850. Three other cases only have since been recorded in England ; one each by Mr. Erichsen, Mr. Holmes, and the late Mr. Statham—An incision along the outer and anterior aspect of the ankle, Avill expose the bone; its neck should then be severed with strong cutting pliers; and, some space having been thus made, the bone may be drawn out of its bed by the lion-forceps, the knife being used to detach its ligamentous connexions, but applied cautiously towards the inner side of the joint in proximity to the plantar arteries. It may be necessary to extirpate the bone piecemeal, when its substance breaks down in a carious state ; it must then be gouged out. Some of the anterior tarsal bones may have to be removed with the astragalus. Liston's Operation on the foot—as the excision thus extended, in a noted case, might be named—consisted in the removal of the astra- galus, scaphoid and two cuneiform bones. The case is reported in the Edinburgh Medical and Surgical Journal of January, 1821. Results.—Of partial excision of the astragalus, in 27 cases recorded ; 8 were operations for disease—caries ; 5 terminated well, 1 ended in anchylosis, and in 2 the result was not stated. Complete Excision.—In 109 cases of complete excision of the astragalus, 14 were operations for disease; 13 being for caries, and 1 for necrosis. Of the 13 cases; 1 died, 8 recovered Avith good and useful limbs, 2 underAvent secondary amputa- tion two years after excision, and both recovered ; in 2 the results were doubtful. The case of excision for necrosis did well. (2) Excision of Os Calcis.—Partial excision seems to have been first performed for injury, in the removal of a musket-ball from the os calcis, by Formius, as long since as the year 1669. Complete excision was first performed, and for disease—necrosis, by M. Robert of Prague in 1837. The second operation, and the first in this country, was by Mr. Hancock in May, 1848. The first successful case in England was by Mr. GreenhoAV of NeAvcastle, in the same year— 1848 ; and two equally successful cases of complete excision, in the hands of that Surgeon, followed also in that year. Since then, the operation has been practised, with varying success, by other Surgeons; principally, by Sir William Fergusson, Teale of Leeds, Humphry of Cambridge, Cann of Hereford, Pemberton of Birmingham, Potter of Newcastle, Mr. Holmes, Mr. Erichsen, and myself. The operation is thus performed :—The patient lying on his face— with the sole of the foot uppermost; an incision, with a stout bistoury, may be commenced at the calcaneo-cuboid articulation, just above the sole of the foot, and carried backAvards round the heel, forAvards, to an equal point on the inner side. This sole flap of integument is raised for- Avards from the under surface of the os calcis, and in its whole thickness doAvn to the bone, so as to form a good cushion; a slight perpendicular incision is made, opposite the tendo-Achillis, into this horizontal incision, and Avith a little reflection of the integument to either side, the tendon is severed from its insertion. The knife is then entered posteriorly, over the upper surface of the os calcis, and the strong interosseous ligament connecting it Avith the astragalus is divided, somewhat as an oyster is opened; the bone can then be raised, and its lateral attachments being cleared by a gentle application of the knife, the calcaneo-cuboid articu- lation is opened, and the bone completely detached. Or, an incision may be made, as for Syme's amputation at the ankle- joint, and a heel-flap having been formed, the os calcis is exposed; lateral 648 SPECIAL PATHOLOGY AND SURGERY. incisions are continued, on either side, along the sole of the foot to the line of the calcaneo-cuboid articulation, whereby a short sole-Rap is reflected forwards; and the operation completed as before. The objection to this plan of excision is the liability to sloughing of the heel-flap, in disease of the os calcis; fistulous openings frequently having formed pos- teriorly, where the flap is attached. The advantage of a heel-flap is that the excision can be readily converted into Syme's amputation, in the event of the astragalus being found to be extensively involved. This method, therefore, was recommended by Mr. Teale, and practised by Mr. Page, as a precautionary proceeding in excision of the os calcis. Apart from the contingency of sloughing, I prefer the sole-flap method of excision. (3) Excision of the os calcis and astragalus—Wakley's Operation—is performed much in the same manner as the second method of excision of the os calcis alone. The only differences are ; an additional incision be- tAveen the malleoli posteriorly, curving down to the insertion of the tendo- Achillis, so as to expose the astragalus, on raising this flap of integument; and, that the integument of the heel between this incision and the incision across the heel, from malleolus to malleolus, forming the heel-flap in the other operation, is here removed. The bones are excised through the gap thus made posteriorly, by dividing the tendon and lateral ligaments; lateral incisions being continued along the foot to the line of the calcaneo- cuboid and astragalo-scaphoid articulations, so as to give access to these articulations. The malleoli are removed with bone-nippers. The pos- terior tibial artery must be ligatured, but the anterior tibial is avoided by very cautiously using the knife, in removing the astragalus in front of the tibia. This excision would probably meet the difficulty of disease extending up to the ankle-joint, and, in such case, prove a substitute for Syme's amputation at the ankle-joint. The operation was performed by Mr. Wakley at the Royal Free Hospital, in December 1847, and the case is reported in The Lancet of July, 1848. Results.—Of partial excision of os calcis, in 42 cases, collected by Mr. Hancock, 38 were operations for disease; 25 for caries, 12 for necrosis Avith sequestra, and 1 necrosis. Of the 25, 1 died the day after operation of diarrhoea, 14 recovered at periods varying from six weeks to six months ; 2 required a second operation but recovered, and 1 underwent secondary amputation ; while of the remaining 7 the result is not given. Of the 12 cases; 3 recovered, 1 required a second operation, 1 secondary amputation; and of 7 the result is not stated. Complete Excision.—Of 18 cases—the particulars of which are authen- ticated—in 14 the disease was scrofulous; and in 11 of these, this con- dition Avas entirely constitutional, in 1 it is said to have originated from a nail having been run into the heel, and in 2 to have followed sprains. Of the 11 cases ; 1 died of diphtheria, 7 recovered and with perfect use of the limb, Avhile 3 suffered secondary amputation—2 from recurrence of disease in the remaining tarsal bones, and 1 owing to erysipelas. Of the 3 cases induced by injury; 2 recovered completely, and the result of the third was doubtful. The general results of complete excision of the os calcis, are thus re- presented in 34 authenticated cases; 1 died of diphtheria, 25 recovered completely, 4 underwent secondary amputation ; and of 4 the results are not given. EXCISION OF THE ELBOW-JOINT. 649 In one case of excision of the os calcis—for caries, I removed also the cuboid bone and a small portion of the external cuneiform bone, both of which were involved in the disease. The patient recovered, and with a thoroughly sound and permanently serviceable foot; this result having been established by two years' duration, when the weight of the body could still be supported by the foot, and the ankle-joint had free motion. He walked without the aid of a crutch or stick. The particulars of this most successful case are reported in The Lancet of July 23, 1864. Compared with sub-astragaloid amputation.—This operation has been little practised in England, but chiefly in France. It appears to have been performed altogether in 22 cases, as collected by Mr. Hancock. The results of some are not stated. Of the whole number; 6 Avere operated on by Malgaigne, 1 by Maisouneuve, and 1 by Nelaton; in 9 collected by Vacquer, all terminated favourably, 1 by Dr. John Trade of Arbroath, was successful; in 2 by Mr. Simon, one was successful, the other patient died of tetanus at the end of a fortnight; in 1 by Garner of Stoke-upon- Trent, the report avus unfavourable, and 1 by Mr. Hancock was successful. The Cuboid, Scaphoid, and three Cuneiform Bones, may severally re- quire Excision; and preferably to removal by Chopart's amputation—in the articular line between the os calcis and astragalus behind and the cuboid and scaphoid in front, Avhereby the two latter tarsal bones, and three cuneiform bones, with the whole of the metatarsus and toes, are sacrificed. But the conditions of disease appropriate for excision rather than amputation, are not determinable by any precise rules; and either operation must be selected according to the judgment of the Surgeon in each particular case. For the operations of excision, no particular directions can be laid down; the lines of incision must be guided by the state of the integu- ment, and the facility for gaining access to the bone and its articulations. The Metatarsal Bones may also be subjected to excision, either at their articular ends, or of the whole bones. These operations of extir- pation are more desirable than the sweeping amputation of the metatarsal portion of the foot, including the toes, by Hey's operation—in the line of the tarso-inetatarsal articulations. The choice of operation must, here again, be determined in each particular case, by the kind and extent of disease. The Toes are not eligible for excision; except at their articulations occasionally, or of the ungual phalangeal bones. Removal of the inter- mediate phalanges will scarcely leave a useful toe. With regard to the great toe; its metatarsophalangeal articulation may occasionally be ex- cised, or the last phalangeal bone removed; thus preserving the ball of the toe for the support of the arch of the foot. But the results of these excisions of the metatarsal bones and phalanges of the toes, or of their articulations, are less successful than in the corre- sponding bones of the hand ; the toes or their contracted portions remain- ing comparatively useless or inconvenient. Elboav-joint.—This joint appears to be, and certainly in my own experience has been, not unfrequently amenable to treatment without operative interference, in the destructive stage of inflammatory disease, by ulceration of the articular cartilages. The natural cure by anchylosis supervenes more readily, apparently, than in other joints; and fibrous union usually occurring, a moveable joint and useful limb is the result. 650 SPECIAL PATHOLOGY AND SURGERY. The following case, which came under my care, is so good an example of this mode of cure, that its history seems worthy of notice. Mrs. P-----, aged forty, states (1857), that in 1840, seventeen years ago, a heavy door slamming, struck her left elbow on the outer side. Some pain and SAvelling ensued, which gradually subsided. Pain, however, was felt occasionally after using the arm, during the next six years. Then the forearm gradu- ally became bent on the arm, but the limb could be forcibly straightened. In 1855, she had rheumatic fever; the injured joint was first affected with acute pain and swelling, and other joints subsequently. The SAvelling of the elbow proceeded to abscess, which broke and discharged matter; leaving seven sinus openings, of which, two in front, and three behind the joint, remained open for the next two years. During ten months of this period, she could not lift her arm to her head, nor feed herself with it. In 1857, the sinuses had all closed, except one Avhich discharged slightly, a little below the head of the radius,—a not uncommon situation of opening in disease of the elbow-joint. The patient's general health remained good, at least there was no approach to exhaustion. Having , regard to the quiescent state of the joint, and the satisfactory state of the constitutional condition, it appeared probable that if sufficient power of nutrition could be evoked, anchylosis Avould ensue. The result more than fulfilled my anticipation. After three months' treatment, by rest, strapping with the emplastrum ammoniaci cum hydrargyro, tonics and diet,—my usual course of treatment for curable joint-disease ; fibrous anchylosis had taken place effectually, and there was limited motion in the joint. Improvement gradually continued, and the range of motion in- creased. In 1861, the patient could roll paste without pain or inconve- nience ; she could lift a nine-gallon barrel of beer and set it on " thrall," and she could make a bed, snaking the mattress or feather-bed without affecting the elbow. Weather, or the east Avind, sometimes gave her slight rheumatic twinges in the joint. In April, 1865, the joint was neither painful nor swollen; all the sinuses had firmly and permanently closed, leaving the bony outline of the natural articulation only somewhat enlarged and irregular in shape. She could flex the forearm to an acute angle with the arm, and both pronation and supination were perfect. The action of the hand and fingers completed the perfect use of the arm. The Conditions of Elbow-joint Disease appropriate for Excision.—The three conditions which severally determine the propriety of excision with regard to the joints in general, are applicable to the elbow-joint. (1) Functional inutility of the limb, depending on disease of the joint having resulted in destruction of the articular cartilages, without the supervention of anchylosis, will always justify excision ; care being taken that the constitutional condition shall not, if possible, have approached to exhaustion. (Fig. 259.) But the degree of reserve power requisite for recovery is much less than after excision of the knee or hip, OAving to the average period of reparation being less by one-half, or about six weeks instead of three months, (2) Osseous anchylosis, and particularly in connexion with a useless position of the limb, will also justify excision. (3) The structural conditions of disease pertaining to the elboAv- joint, which specially affect the propriety of its excision, relate to the extent of bone destroyed by disease. The limits of excision of the elbow- joint are not restricted by two of the three considerations respecting the knee-joint. Thus, the length of the portions of bone removed from the CONDITIONS OF ELBOW-JOINT DISEASE FOR EXCISION. 651 elbow is comparatively unimportant; the corresponding loss of length in the arm not much impairing the use of this member eventually, nor is it of consequence, therefore, to observe the epiphyseal lines as affecting the subsequent growth of the bones. But it is equally requisite in the elbow as in the knee to preserve sufficiently wide surfaces for the forma- tion of an adequately secure union; in the one case, with ligamentous mobility; in the other, with osseous consolidation. The removal of only a thin superficial section of Fig. 260. the articular ends of the bones in the elbow-joint, leaving the section ends too nearly in contact, is apt to be followed by osseous union and an unsuc- cessful result of the operation. On the other hand, any new bone Avhich may not unfrequently have been produced in the form of a spiculated enlargement of the articular ends above their diseased portions, and thereby limiting the disease, should not be in- cluded in the excision. (Fig. 260.) The impor- tance of observing this limitation of the operation is particularly urged by Mr. Butcher in his work on Operative and Conservative Surgery. Operation.—Excision of the elbow-joint, for disease. Avas originally performed by Justamond, of the Westminster Hospital, in 1775,—as a partial operation, in Avhich the olecranon and tAvo inches of the ulna Avere removed; complete excision was first performed by Moreau, senior, in 1794, and by Moreau, junior, in 1797; but the operation attracted little attention until it was revived by Stansfield, Chorley, and Hey of Leeds, in 1818-19; and especially by Syme in 1830; since Avhich period it has been more generally practised than the excision of any other joint for disease. The operation is thus performed:—a single linear incision |, longitu- dinally over the centre of the joint, and of sufficient length to turn out the bones, is preferable to any other, in relation to speedy recovery after operation. Other forms of incision offer certain special operative advan- 652 SPECIAL PATHOLOGY AND SURGERY. An H shape exposes the bones more readily, on reflecting the flaps, thus marked out, upwards and downwards; and this incision is particularly recommended by Sir W. Fergusson. (Fig. 261.) A H shaped incision Avith the vertical line parallel to and a little outside the ulnar nerve, allows of its being more surely guarded or drawn inwards, by a curved spatula in the hands of an assistant. In either case, the transverse line of these incisions should be made across the end of the olecranon from condyle to condyle; or nearly to the inner condyle, in the latter form of incision ; and thus the joint is laid open. But the single longitudinal incision is now, I believe, generally practised, and I rarely find any other more conve- JL nient. With a little detachment of the integument on either side, the knife is entered transversely above the olecranon, dividing the tendon of the triceps,—the ulnar nerve being protected; the olecranon process must then be sawn off transversely, and by forcibly flexing the arm, and, perhaps, dividing the lateral liga- ments with a light touch of the knife, the articular surfaces of the three bones are fully protruded and ex- posed. The articular surface of the humerus, between the condyles, is excised by means of a small saw ; and the remaining sigmoid surface of the ulna and head of the radius, in like manner, or removed with pliers, or simply gouged. The latter two bones should not be excised below the insertions of the brachialis anticus and biceps muscles; for thus the brachial artery will be protected by the intervening brachialis muscle from any fair risk of injury, in removing these portions of bone. Any surrounding out-growth of bone, resulting from exuberant reparative action, must not be mistaken for disease; it should not be included in the excision. The line of incision having been closed with sutures, the arm is laid semiflexed on an angular splint; or it may be placed in Mr. Christopher Heath's splint, an apparatus which combines with rest and graduated flexion or extension, graduated elongation of the limb, and entire access to the joint for dressing. To ensure the formation of flexible union, passive motion should be gradually recommenced when such reparation is established; say, in three or four weeks. Results of excision of Elbow-joint.—(1) In relation to Life, or the Mortality.—Three general conclusions may be drawn from the results of one large collection of cases; those, in the Ilospitals of the United Kingdom, and in the practice of individual Surgeons,—(1) a lower mor- tality than that of any joint-excision in the lower extremity; and in the upper extremity also, so far as statistics hitherto collected supply the data for comparison. (2) An average mortality of 1 in 8, or 12 per cent.; or even much lower, about 1 in 15, or about 7 per cent. (3) A very different mortality in the hands of individual Surgeons. RESULTS OF ELBOW-JOINT EXCISION. 653 The conditions of disease, local and constitutional, in the cases selected for operation, would seem to mainly determine this difference; Avhile, the mode of performing the operation, and the after-treatment, would also contribute to explain it. The collection of cases, by Dr. Hodges, amounts to 119; of these, 15 died, 1 in 8, or 12 per cent. Author's Collection. (1) Royal Infirmary, Edinburgh; period, 1865-69. (Per Mr. P. H. Watson.) Number of cases, 62; recoveries, 50; deaths, 12. (2) Liverpool Royal Infirmary; period, last five years. (Per Mr. W. J. Cleaver.) Number of cases, 30; recoveries, 29; deaths, 1 ; amputation after excision, 1 ; recoveries, 1. (3>) St. BartholomeAv's Hospital; period 1866-70. (Per Mr. Cal- lender.) Number of cases, 19; recoveries, 17; deaths, 2; amputations after excision, 2; recoveries, 1 ; deaths, 1. (1) Cuy's Hospital; period, 1861-69. (Per Mr. T. Bryant, from Dr. Steel, Superintendent.) Number of cases, 19; recoveries, 17; deaths, 2. (5) Chalmers Hospital, Edinburgh ; period, last six years. (Per Mr. P. II. Watson.) Number of cases, 15 ; recoveries, 14 ; deaths, 1 ; re-excisions, 1 ; recoveries, 1. (6) London Hospital; period, last five years. (Per Mr. McCarthy.) Number of cases, 14 ; recoveries, 12 ; deaths, 2. (7) King's College Hospital; period, last five years. (Per the House Surgeon.) Number of cases, 12; recoveries, 11 ; deaths, 1. (8) Westminster Hospital; period, last five years. (Per Mr. F. Mason.) Number of cases, 12 ; recoveries, 12. (9) Charing Cross Hospital; "period, 1860-65. (Per Mr. Hancock.) Number of cases, 8 ; recoveries, 8. (10) St. Mary's Hospital; period, last five years. (Per Mr. Gas- coyen.) Number of cases, 8 ; recoveries, 8. (11) Royal Free Hospital; period, last seven years. Number of cases, 7 ; recoveries, 6 ; deaths, 1. (12) Royal Sea-Bathing Infirmary, Margate; period, last five years. (Per Mr. J. R. Clouting.) Number of cases, 6; recoveries, 6 ; re-exci- sions, 2 ; recoveries, 2. (13) St, Thomas's Hospital; period, 1866-70. (Per Mr. F. Churchill.) Number of cases, 4; recoveries, 4. (14) Royal Albert Hospital, DeAronport; period, last five years. (Per Mr. W. P. Swain.) Number of cases, 2; recoveries, 2. (15) Great Northern Hospital; period, last five years. (Per Mr. J. Willis.) Number of cases, 1 ; recoveries, 1. Compared with Mortality of Amputation of the Arm.—By Malgaigne's statistics from the Parisian Hospitals we find ; of 61 cases, for disease, 4 deaths resulting, or 6-5 per cent. ;—a lower mortality than that after excision of the elbow-joint. But the statistical results from University College Hospital, furnished by Mr. Erichsen, show afar higher mortality after amputation. Of 18 cases of amputation of the shoulder and arm, for disease; 5 died, or 27*7 per cent. (2) State of the Limb.—Of the 104 recoA^eries out of 119 cases, the majority (minus 15 amputation cases) had useful limbs, as proved by the patient being able to resume his ordinary avocations; but the details 654 SPECIAL PATHOLOGY AND SURGES Y. given respecting the kind and extent of motions left are not exact. The subjoined figure represents the resulting appearance of the elbow, and arm, after excision of the joint, in a case operated on by Sir W. Fer- gusson. (Fig. 262.) The average duration of the process of recovery cannot be gathered from recorded cases. In about three weeks generally, passive motion may be commenced, and fibrous union be completed in six weeks; a more rapid progress by half the average period requisite for osseous union, after excision of the corresponding joint in the lower limb—the knee. The resulting state of the joint, is commonly fibrous and flexible union, rarely osseous and fixed anchylosis; the former, of course, being the result desired. In an interesting case, which Mr. Syme had the opportunity of dissecting nine years after the operation of excision of the elbow, for injury ; the ulna was found united to the humerus by ligament, while the end of the radius was polished off, and played on the humerus and ulna, a material like cartilage being interposed. The ends of the bones of the forearm were locked in by two processes pro- jecting downwards from the humerus, and strong lateral, and still stronger anterior and posterior ligaments, also bound them to the latter bone. Dissections of several cases, after successful excision of the elboAv, may be found in Wagner on " Repair after Resection ; " and it would seem that the general result is,—union, by more or less extensible liga- ment. Flexion, according to M. Robert, is composed of two movements; the forearm being first drawn up to the humerus by the triceps, and then flexed by the action of the biceps. The joint becomes nearly as useful as the original articulation. Thus, in Mr. Syme's case, the man —a railway guard, could swing himself from one carriage to another Avhile the train was in motion, with the injured arm, quite as easily and securely as with the other; and in one of Mr. Butcher's cases, the man could lift a bucket of water, holding four gallons, and carry it to and fro, or lift it on to a table three feet high. Then again, the freedom of the anchylosis for the more delicate movements of the forearm and hand, was well exhibited in one of my own cases (Case 1); a milliner and dressmaker who could work with her needle readily and untiringly,—a seven years' permanent result of excision. Injury of the ulnar nerve—an occasional accident during the opera- TYPICAL CASES OF ELBOW-JOINT EXCISION. 655 tion—is folloAved by loss of sensation in the little finger and adjoining side of the ring finger, with perhaps loss of motion and wasting of the muscles ; but the sense of touch will probably return, and the other ill- consequences cease, apparently by re-union of the wounded nerve. This accident, judging from the digital paralysis, happened apparently in one of my own cases,—that of the milliner just mentioned; but the symp- toms passed off entirely, as the functional use of the finger showed. Re-excision may be practised, as in the knee—Avhen necessary, rather than resort to amputation; and even a third such attempt has, it is said, been made with good results. In my table of Hospitals, 219 cases ; of the 197 recoveries from the primary excision, 3 only are noted as having undergone re-excision, but with no death. Of my own 5 cases, I had to re-excise 1, and Avith a thoroughly successful result,—the patient resuming his occupation as a postman. Secondary amputation.—Of the 104 recoveries after excision, in Hodges' collection of 119 cases, 15 of that number underwent amputa- tion subsequently. From the collection of Hospitals, we learn; that of the 197 recoveries, 3 only were subjected to amputation, Avith one fatal issue. The folloAving cases in which I excised the elbow-joint, for disease, are here grouped together, as exhibiting the most essential particulars relating to the question of this operation ; and the permanent results are also stated. _ The notes from which I have draAvn up these abstracts were carefully taken, excepting in the first case, by Mr. T. C. Murphy, Senior House Surgeon at the Royal Free Hospital. Typical Cases of Elboaa7-joint Excision.—Case 1.—Margaret R----, aet. 25. Chronic synovitis, of traumatic origin, one and a half year's duration, one year and two months' treatment. Partial ulceration of the articular cartilages of the humerus, ulna, and radius; with semi- flexed position of the limb. Excision. Recovery, Avith a moveable joint and useful limb, in six Aveeks. Result known to be permanent after seven years. For the particulars of this case I am indebted to my colleague, Mr. John D. Hill, then Senior House Surgeon in the Hospital. Case 2.—Thomas H. B----, aet. 29. Chronic synovitis of traumatic origin, one year's duration and treatment. Ulceration of the articular cartilages of the humerus, ulna, and radius ; with semiflexed position of the limb. Excision. Recovery, with a partially moveable joint. Subse- quent formation of abscess and sinuses. Re-excision. Recovery, with a moveable joint and a limb useful, in flexion, extension, pronation, and supination. Result known to be permanent after one year and four months. Case 3.—Mary M----, aet. 28. Acute synovitis of traumatic origin, one month's duration. Partial ulceration of the articular cartilages of the humerus, ulna, and radius, with subjacent caries ; a semiflexed position of the limb ; excessive and paroxysmal pain. Excision. Recovery, with a moveable joint by passive motion, in six weeks. Result known to be permanent after one year. Case 4.—Jane T----, aet. 31. Scrofulous caries of the ends of the humerus and ulna in the elbow-joint. Ulceration of the articular carti- lages, Avith semiflexed position of the limb. Excision. Recovery with a partially moveable joint by passive motion, in two months. Permanent result, at the end of six months, uncertain. 656 SPECIAL PATHOLOGY AND SURGERY. Case 5.—Lewis P-----, aet. 50. Caries of the olecranon, of idiopathic origin, ten months' duration and treatment; idiopathic abscess opposite the outer condyle of the humerus, six years previously. Carious bone gouged out of the olecranon. The joint opened in this procedure. Excision of the olecranon and of the end of humerus. Recovery, with a moveable joint. Shoulder-joint.—Disease of the shoulder-joint occurs so much less frequently than that of other joints, as to considerably restrict the opportunities for clinical observation respecting its seat of origin; the probability of natural anchylosis ensuing, or the necessity for operative interference by excision to bring about that issue. The synovial mem- brane, in some cases, would appear to be the seat of the disease; and then—suppuration being a rare event, fibrous anchylosis usually ensues. But caries, in other cases, is the mode of origin,—affecting the head of the humerus, less commonly the glenoid cavity, or only secondarily and partially; and then natural anchylosis rarely takes place. Caries, ex- ternal to the joint, as of the coracoid process, the acromion, or spine of the scapula, must not be confounded with disease of the shoulder-joint. Thus, may be recognised as indications for operation, the following. Conditions of Shoulder-joint Disease, appropriate for Excision :— (1) When disease, commencing either in the synovial membrane, or as caries, has extended to and destroyed the articular cartilages, of the head of the humerus, or of the glenoid cavity of the scapula, or of both surfaces; Avithout the supervention of anchylosis. The constitutional condition should not have advanced to exhaustion ; although, in even an extreme state of hectic and emaciation, recovery after excision of the shoulder-joint is more probable than after such operation on any other large joint. Necrosis of the head of the humerus, generally necessitates excision of this portion of bone; but sometimes, in central necrosis, the seques- trum can be extracted, without excision. Caries or necrosis of the coracoid process, or of the acromion, is, of course, a condition of disease not requiring excision of the joint. (2) Osseous Anchylosis, a rare condition, with perhaps mal-position of the limb, would scarcely ever justify the risk of excision. The amount of bone to be removed is rarely extensive; the disease being limited usually to the head of the humerus, while the glenoid cavity is comparatively seldom affected, and even then may usually be left untouched, or only scraped. Operation.—Excision of the shoulder-joint, for disease, is commonly said to have been originated by Mr. Charles White, of Manchester, in April, 1768. He had previously excised the head of the humerus on the dead subject; but the operation in question consisted in removing the upper part of the humerus for necrosis, leaving the head of the bone in the glenoid cavity. Similar excisions were performed by Vigaroux, of Montpellier, in 1767, and perhaps by David, of Rouen. Ridewald, in April, 1770, appears to have first removed the head of the humerus, for arthritic disease, the patient being a man, fifty years old, in a wretched condition of health; secondary amputation was resorted to for suppura- tion and haemorrhage, and death ensued. This operation was followed in the next year, 1771, by another case; Mr. James Bent, of Newcastle, excised the head of the humerus for caries, of three years' standing, and with entire success. In the same year, the operation was performed EXCISION OF SHOULDEP-JOINT. 657 Fig. 263. by Leutin ; then in 1778, by Mr. Daniel Orred, of Chester; and in 1786, by the elder Moreau,—a complete excision of the head of the humerus, the glenoid cavity, and a portion of the acromion; the result being suc- cessful. Mr. Syme revived the operation in 1826. An elliptical incision, [J, is the best form of incision, as it exposes the joint most thoroughly for examination, and facilitates the application of instruments. Sometimes a |, or a ~] or a T incision may be prefer- able ; and, in truth, the shape of the flap must be guided by the state of the integument with regard to sinuses or otherwise. Supposing an ellip- tical to be selected;—A bistoury is entered at the posterior border of the acromion and carried down with a sweep across the inser- tion of the deltoid, upwards to the inner border of the coracoid process. The flap, embracing the deltoid muscle, is raised by a feAv touches with the knife; and, by slight adduction and rotation of the arm, the head of the humerus is turned out of the glenoid cavity,—the capsular ligament having dis- appeared. Or, the single linear incision may be made. (Fig. 263.) An assistant protect- ing the soft jvirts with a spatula on the inner aspect of the bone, the saw is applied below the diseased portion. The head, neck, and proximate part of the shaft may be thus removed; avoiding if possible the circumflex arteries. Any carious portion of the glenoid cavity may be scraped with a gouge. As a rule, with very rare exceptions, the glenoid cavity should not be excised. The flap is replaced, and retained by sutures; and the arm, Avith an axillary pad, may be bound to the chest, as for fractured clavicle ; or supported on a pillow, extending as a splint from the axilla. Sub- sequently, the forearm must be supported in a sling. Results of E.rcision of the Shoulder-joint.—(1) In relation to Life, or the Mortality.—Statistics are not, at present, sufficiently comprehensive to establish more than one general conclusion respecting this question. The average mortality appears to be 1 in 5, or 6; 20 per cent., or about 16 per cent., respectively. Of 50 cases, collected by Dr. Hodges, 8 died; 1 in 6, or about 16 per cent.; and in 7 of the 8 fatal cases, the glenoid cavity had been interfered Avith. Of the 30 cases in the Hospital collec- tion beloAV, the death-rate Avas nearly 1 in 4, or 25 per cent. Author's Collection. (1) Royal Infirmary, Edinburgh ; period, 1865-69. (Per Mr. P. H. Watson.) Number of cases, 10; recoveries, 7 ; deaths, 3. (2) Liverpool Royal Infirmary ; period, last five years. (Per Mr. W. J. Cleaver.) Number of cases, 7; recoveries, 6; deaths, 1. (3) London Hospital; period, last five years. (Per Mr. J. McCarthy.) Number of cases, 3 ; recoveries, 1; deaths, 2. (4) Westminster Hospital; period, last five years. (Per Mr. F. Mason.) Number of cases, 3 ; recoveries, 3. (5) St. Bartholomew's Hospital; period, 1866-70. (Per Mr. Cal- londer.) Number of cases, 2 ; recoveries, 1 ; deaths, 1. 658 SPECIAL PATHOLOGY AND SURGERY. (6) Guy's Hospital; period, 1864-69. (Per Mr. T. Bryant, from Dr. Steel, Superintendent.) Number of cases, 2 ; recoveries, 2. (7) St. Thomas's Hospital; period, 1866-70. (Per Mr. F. Churchill.) Number of cases, 1; recoveries, 1. (8) Charing Cross Hospital; period, 1865-70. (Per Mr. Hancock.) Number of cases, 1 ; recoveries, 1. (9) Royal Free Hospital; period, 1865-70. Number of cases, 1 ; recoveries, 1. (10) King's College Hospital; St. Mary's Hospital; Great Northern Hospital; Royal Albert Hospital, Devonport; Chalmers Hospital, Edin- burgh ; Royal Sea-Bathing Infirmary, Margate; period, each last five years. No cases. (2) State of the Limb.—In 4 of the 50 cases, collected by Hodges, the operation Avas unsuccessful; leaving a balance of 16 successful cases. The average period of recovery, with some use of the limb, as calcu- lated from 31 of the cases, Avas four months; "a much longer period, however, than this elapsed, before the limb could be said to become really serviceable." The resulting state of the joint, Avould seem to be, that the limb can never be elevated above the horizontal line, while in many cases it hangs down, without any power whatever in the deltoid, at a greater or less distance from the scapula. But the movements of flexion, extension, and adduction are usually free; abduction can often be effected to the extent of raising the arm considerably from the side ; and there is generally sufficient power in the forearm to carry heavy weights, and perform many of the ordinary domestic tasks. The arm is, therefore, a very useful one, irrespective of the vast importance of preserving the hand ; and thus the person is enabled to folloAV many of the ordinary trades. The following cases well illustrate the successful results of shoulder- joint excision, for disease. I have abstracted the first case from careful clinical notes by Mr. T. C. Murphy. Case 1. John C----, aet. 21. Admitted into the Royal Free Hospital, July 30th, 1870. The patient, of naturally good constitution, had never suffered from rheumatism ; but for the last two years, he had habitually drank hard. At about the commencement of that period, he was struck with a stick on the right shoulder; three months aftenvards, a small abscess formed at the anterior margin of the axilla, it was opened, and has continued to discharge ever since. The arm gradually became more fixed and drawn to the side. In the course of six months, a large abscess, the size of a fist, formed under the spine of the scapula; this Avas opened at St. BartholomeAv's Hospital. Other abscesses have since formed ; so that, on admission, the shoulder presented considerable enlargement, and seven sinus-openings—three posteriorly, tAvo externally through the deltoid muscle, and two anteriorly in the angle of the axilla. From the date of injury, up to the present time, the joint has been painless, unless the arm was forcibly moved. The general health is much reduced by the profuse and long-continued discharge. I, therefore, endeavoured to restore the patient, as far as possible, constitutionally and locally, by a sustaining diet and rest of the joint; and, as he retrogressed occasionally, from attacks of diarrhoea, I postponed interference, watching the most favourable op- portunity for operation. At length, after two months and a half of this manoeuvring, on October 15th, I excised the joint; performing the operation by the elliptical incision, so as to embrace and raise the deltoid muscle, thus to thoroughly expose the whole joint. The remnant head of RESULTS OF SHOULDER-JOINT EXCISION. 659 the humerus was sawn through below the great tuberosity ; observing my usual precaution, in all joint-excisions, not to detach the vascular con- nexion of the surrounding integument, and making the section just level with its attachment. The glenoid cavity, denuded of cartilage, was Blightly scraped and freshened Avith a gouge. Torsion of one or two small A-essels, and one ligature, sufficed to arrest the trifling haemorrhage. The flap being laid down, and closed by a few points of suture, no reten- tive splint Avas applied ; an axillary pad, and a bandage as for fractured clavicle, kept the osseous surfaces in apposition, and the arm on the chest. The wound healed throughout by primary union, discharging only from its angles, while the sinus-openings gradually dried up. The result, at the end of about six weeks, Avas, a freely moveable joint, in all directions— circumduction and rotation ; Avith power to perform these movements, but only to a limited extent that of raising the arm by abduction horizontally. The general health had so far improved ; that, regaining some flesh and strength, the patient became cheerful, and said '• he felt better than he had done for years." He left hi3 bed daily. Subsequently, however, attacks of diarrhoea recurred from time to time, and the abdomen became tumid and tympanitic; enlargement of the liver, assumed to arise from amyloid or albuminous degeneration, was diagnosed by my colleague, Dr. Cockle—under whose care the patient has since remained. He died from this organic disease, on February 4th,—3^ months after the operation, from Avhich he had entirely recoA'ered, and with a freely moveable joint. P. M. examination verified the diagnosis, and preserved the articulation, as a perfect specimen of a neAV ball-and-socket-joint; an entire capsular ligament has formed, and the section-end of the humerus moves freely on the glenoid cavity of the scapula—in circumduction and rotation. Case 2.—E----- F----, aet. 17, a young lady, the daughter of a practitioner Avell known in this Metropolis. I Avas invited by him (January, 1871) to witness the result in this case, and I am thus enabled of my know- ledge to speak of its perfect and permanent success ; at the same time, he communicated the folloAving important particulars to me respecting its history :■—Six years ago, Avhen this young lady Avas betAveen 10 and 11 years of age, she apparently took cold, Avhile resting on a seat in Hyde Park. Her previous health having been ahvays good, and as she had never received any injury to the shoulder, this Avas the only assignable cause of Avhat took place. The right shoulder-joint became very painful, and acute inflammation set in, followed by free suppuration in 48 hours. Dr. Sibson saAV the case, and then, by his recommendation, Mr. Samuel Lane, Avho immediately opened the abscess. It continued to discharge copiously, for two months; so abundantly indeed, that the father, who measured Avith an half-ounce spoon, the quantity of matter discharged from day to day, thus calculated that the patient lost during this short period, three gallons of pus. Her constitutional condition, accord- ingly, Avas much reduced. Then—two months from the date of apparent origin—Mr. Lane excised the shoulder-joint, assisted by Mr. James Lane, and Mr. Gascoyen, Mr. Pollock and the father also being present. A lon"-itudinal incision Avas made on the front of the humerus, apparently at the inner border of the deltoid muscle, from opposite the coracoid process doAvnwards to about three inches in extent, and a short transverse cut superiorly ; forming a T-shaped incision. Tavo inches and a half (if the humerus Avere removed, and the glenoid cavity, in a deeply carious state A\ras freelv gouged. The patient made an uninterrupted recovery ; 660 SPECIAL PATHOLOGY AND SURGERY. as reparation ensued, the appetite became voracious, and assimilation equally active. Nourishing food—meat, eggs, milk, Avith port wine, champagne, porter, &c, Avere taken eagerly at frequent intervals, by day, and even in the night. Being naturally intelligent, she declined any tonic medicine, as she felt her flesh and strength returning; her suggestive remark being,—" Which do you think will do me the most good, that which I like, or what I don't like?" The voice of Nature, thus proclaimed by Nature's child, was heeded. She made a complete recovery, and the result is—that, although the arm is four inches snorter than its fellow, she moves it freely backwards and forwards, Avithout, however, the power to raise it horizontally, unless aided by the left hand. The motions of the forearm are perfect, so that she can work readily, write, or play the piano. The limb is, therefore, a most useful one, and this result has now been permanently established by six years' service. Wrist.—Excision of the wrist comprises, properly speaking, not only the removal of the articulatory portions forming the radio-carpal articu- lation or wrist-joint, but also the carpus, and bases of the metacarpal bones ; this extent of excision differing from that of the analogous opera- tion on the ankle-joint, which is restricted to the removal of the articu- latory portions of the tibia and fibula with that of the astragalus. Conditions of Wrist-disease appropriate for Excision.—Partial, or complete disease of the wrist cannot be referred, like that of the larger and more simple joints, to an independent origin, either in the synovial membranes—three in number, or in the bones of the Avrist. The lower articular end of the radius—and that of the ulna, which in relation to excision is associated with the wrist; the carpus beloAV, consisting of eight bones, in two ranges of four in each; and the bases of the five meta- carpal bones; are all so contiguous, as to obscure the precise seat of origin in caries affecting the wrist. Then again, the three synovial mem- branes are as one, in relation to the origin of disease in the form of synovitis;—the membranous investment of the radio- carpal articulation, wdiich sometimes communicates with that of the radio-ulnar articulation through a perfora- tion in the intervening triangular fibro-cartilage; the investment between the tAvo ranges of carpal bones, with its two prolongations upwards, and sometimes extend- ing into the synovial membrane of the radio-carpal articulation, and the three prolongations downwards which always extend to and invest the four inner carpo- metacarpal articulations; and the separate synovial sac for this articulation in the thumb. Caries of the wrist appears to be generally of scro- fulous, and thence constitutional, origin—excited per- haps by some injury, of apparently trifling character, as a sprain; while synovitis seems to have another con- stitutional origin, probably as chronic rheumatism. Thus, Ave recognise as conditions of disease for excision : — (1) Scrofulous caries of the Avrist; often involving the lower articular end of the radius, and ulna, the whole of the carpal bones, and the bases of the metacarpal bones, in a state of extensive caries. (Fig. 264.) This figure represents the wrist before excision of the lower end of the radius, in a case operated on by Mr. Hancock. CONDITIONS OF WRIST-DISEASE FOR EXCISION. 661 (2) Chronic synovitis, of perhaps more limited extent, but leading to caries and destruction of the articulations. The amount of bone to be removed, as being apparently diseased, may vary according to the character and extent of the disease. Thus excision might include the loAver ends of the radius and ulna, Avith the adjoining carpal bones,—in the wrist-joint; or, the bases of some or all of the metacarpal bones. But, Professor Lister insists on the complete extirpa- tion of the Avrist, in all cases,—from the lower ends of the radius and ulna to the bases of the five metacarpal bones, inclusive ; the disease, however limited it may appear, being apt to recur in the articulatory portions left by a partial excision. Operation.—Excision of the wrist was originally performed by the younger Moreau, at the close of the last century; subsequently, by a German Surgeon, Dietz, in 1839 ; and then again by Heyfelder of Erlan- gen, in 1849 ; but, in this country, the operation was revived by Sir William fergusson, in August, 1851. Since that period, it has been re- sorted to by Mr. Simon, Mr. Erichsen, the late Mr. Stanley, and Mr. Butcher of Dublin; and practised especially by Professor Lister of Edin- burgh, who has devised a particular method of operation,—for complete excision of the wrist. Partial excision, consists in the removal of only one or two of the carpal bones, or other limited portions of the bones, forming the wrist. This procedure can be readily effected by slitting up any fistulous aper- ture leading to the carious bone, and extracting it by bone-nippers and forceps. Complete excision may be performed in either of three ways. The choice of method is mainly determined by the consideration of difficulty in removing the affected bones, without dividing the extensor tendons of the fingers and thumb; the supinator tendons, radial and ulnar extensor tendons, inserted into the bases of metacarpal bones, being comparatively unimportant, in consequence of the firm fibrous anchylosis of the wrist after operation, if the result be successful. First method.—A curvilinear incision is made, extending from just above the styloid process of the radius, doAvmvards across the back of the Avrist, and upwards to the same level above the styloid process of the ulna ; the flap of integument is reflected, carefully avoiding the extensor tendons of the fingers, and those of the thumb, on the ulnar half of the radius. Then, dividing the supinator tendons, and the extensor tendons of the carpus, and flexing the wrist, the radio-carpal articulation is opened; and, while the other extensor tendons referred to are drawn aside Avith a curved spatula by an assistant, the articular ends of the radius and ulna, the carpal bones, and bases of the metacarpus, are successively removed by a small saw or cutting pliers introduced trans- versely. Second method.—Two lateral longitudinal incisions are made, one on the ulnar, the other on the radial side, of the wrist, or on its dorsal aspect; thus readily avoiding the extensor tendons of the fingers, and that of the first joint of the thumb. The operation is then continued as before, and completed by excising the bones in the same manner. A single ulnar incision is deemed sufficient by Sir W. Fergusson, and as the best mode of operation. (Fig. 265.) The resulting ap- pearance is shown by the accompanying figure in Mr. Hancock's case. (Fig. 266.) But Professor Lister has particularly pointed out, there are two 662 SPECIAL PATHOLOGY AND Sl'RC.ERY. obvious and important objections to the lateral method, Avhich someAvhat resembles that which he has devised. Firstly, the radial incision is so placed, as probably to sacrifice the extensor tendons of the metacarpal bone, and of the second joint, of the thumb. Secondly, Avith regard to the Fig. 265. bones ; that in the transverse division of the bones, an unnecessarily large amount of bone is removed from the radius and ulna and from the meta- carpus,—a loss of length and breadth Avhich interrupts the process of Fig. 2G6. consolidation, and results in a more narrow wrist and impaired strength of the hand. Moreover, that the bones being divided in the dark, some portion of the disease may probably be left behind. To obviate these difficulties as to the excision of the bones, and to avoid the tendons requisite for the efficient use of the hand and fingers; another method of operation has been proposed and practised by Professor Lister. It consists in two essential peculiarities :—the radial incision is so placed, on the dorsal aspect of the radius, as to avoid the tendons which are otherwise liable to be implicated—the extensor ossis metacarpi pol- licis, and the extensor secundi internodii; while the limited, but com- plete, excision of the bones is accomplished, by first removing the carpus, and then the articular ends of the radius and ulna, and the bases of the five metacarpal bones. . This procedure is confessedly complicated in its detail,—" consisting of a series of operations, each one of which must be executed with scrupulous care," and it demands accurate anatomical knowledge—an objection of no reasonable weight; the operation is also tedious to the Surgeon in its performance, and protracted for the endu- rance of the patient even under the influence of chloroform. These apparent objections, as to the nature of the operation itself and its per- formance, would, however, be entirely overruled by its more successful results, as compared with the simple procedures already noticed. How far this estimate may be in favour of the complicated method of operation, will be fairly shown by the comparative results of both in Mr Lister's practice. But, in justice to a neAV operation, no less than to its originator, I EXCISION OF THE WRIST. 663 must first describe it; abridging the procedure as little as possible from his own description, although at the risk of proving somewhat wearisome, for all the details are urged as being found well worthy of attention. Third method, or Lister's operation.—Chloroform having been admi- nistered, a tourniquet is placed upon the limb to prevent oozing of blood, which would interfere with the careful scrutiny to which the bones must be subjected. Any adhesions of the tendons are thoroughly broken down by freely moving all the articulations of the hand. The radial incision is then made. It commences above at the middle of the dorsal aspect of the radius, on a level with the styloid process, this being as close to the angle where the tendons of the secundi internodii pollicis and indicator meet, as it is safe to go. At first, it is directed towards the inner side of the metacarpo-phalangeal articulation of the thumb, recurring parallel to the tendon of the extensor secundi internodii; but, on reaching the line of the radial border of the metacarpal bone of the forefinger, it is carried down- wards longitudinally for half the length of that bone, thus avoiding the radial artery which lies somewhat to the outer side. These directions will be found to serve, however much the parts may be obscured by inflammatory thickening. Next, the soft parts at the radial side of the incision are detached from the bones with the knife guided by the thumb-nail; so as to divide the tendon of the extensor carpi radialis longior at its insertion into the base of the second metacarpal bone, and raise it, along with that of the extensor carpi radialis brevior previously cut across, and the extensor secundi internodii, while the radial artery is thrust somewhat outwards. Then, the trapezium is detached from the rest of the carpus, by means of cutting-pliers applied in a line Avith the longi- tudinal part of the incision, but the removal of this bone is postponed until the rest of the carpus has been taken away, when it can be dissected out without much difficulty; the one procedure also not endangering the radial artery, the other having that risk. The soft parts on the ulnar side of the incision are dissected up from the carpus as far as may be con- venient, the remainder being raised by the second or ulnar incision. This incision, a free one, should commence at least tAvo inches above the end of the ulna, immediately anterior to the bone, it is carried down between it and the flexor carpi ulnaris, and onwards in a straight line to the middle of the fifth metacarpal bone at its palmar aspect. The dorsal lip of this incision is raised, and the tendon of the extensor carpi ulnaris is cut at its insertion into the base of the fifth metacarpal bone, and is dissected up from its groove in the ulna, without isolating it from the in- teguments which Avould endanger its vitality. Then the extensor tendons of the fingers are readily separated from the carpus, the hand being bent back to relax them, and the dorsal and internal lateral ligaments of the Avrist-joint are divided; leaving the connexions of the tendons with the radius undisturbed. The anterior surface of the ulna is cleared, turning the knife toAvards the bone to avoid the artery and nerve, the articulation of the pisiform bone is opened,—if not already done in making the inci- sion, and the flexor tendons are separated from the carpus, the hand being depressed to relax them. To accomplish this, the process of the unciform bone must be clipped off with pliers, but the pisiform bone is left attached to the tendon of the flexor carpi ulnaris. In raising the tendons, the knife must not pass beloAV the bases of the metacarpal bones, to avoid wounding the deep palmar arch. The anterior ligament of the wrist-joint is noAV divided. Then, introducing a pair of bone-forceps, the junction 664 SPECIAL PATHOLOGY AND SURGERY. between the carpus and the metacarpus is severed, thus completely detaching the whole carpus, Avhich is extracted en masse with a pair of sequestrum-forceps,—leaving the trapezium and pisiform bones. The ends of the radius and ulna are noAv made to protrude, from the ulnar incision, by everting the hand ; and according to their state of caries on examination, the articular surfaces only, or a larger portion of the bones, should be excised. The end of the ulna may be saAvn obliquely, remov- ing the articular surface, but leaving the styloid process, and the ulna, therefore, of the same length as the radius ; a provision for the subse- quent symmetry and steadiness of the hand, the angular interval between the bones being filled by fresh ossific deposit. The end of the radius is then excised, by saAving off a thin slice, parallel to the general direction of the inferior articular surface. In doing this, the tendons in their grooves on the dorsal aspect of the bone need not be disturbed; it is suffi- cient to remove the bevelled ungrooved part of the bone-end, and thus the extensor secundi internodii pollicis may never come into view. This may seem a refinement; but the freedom with which the thumb and fingers can be extended, even within a day or two after the operation, when this point is attended to, shows its importance. The articular facet on the ulnar side of the radius is then clipped off with bone-nippers, applied longitudinally. In thus excising the ends of the ulna and radius successively, it is far better to take away too much bone than too little ; a useful hand resulting in spite of very extensive excision. The bases of the metacarpal bones must then be examined and excised, saving as much bone as possible, but clipping off their articular surfaces transversely and laterally j even, when necessary, drilling the shaft into a hollow tube. The second and third bones are most easily reached from the radial inci- sion, the fourth and fifth from the ulnar side. Next, the trapezium is seized with a strong pair of forceps and dissected out, carefully avoiding the tendon of the flexor carpi radialis, Avhich lies firmly bound into the groove on the palmar aspect of this bone, and turning the knife close to the bone elsewhere to avoid wounding the radial artery. Then, having removed the trapezium, the base of the metacarpal bone of the thumb is pushed up and its articular surface clipped off; thus preventing the risk of recurrent disease, and reducing the thumb in length to the same extent as the fingers. Lastly, the pisiform bone should be examined, and its articular surface clipped off; the rest of the bone is left, if sound, as it retains the insertion of the flexor carpi ulnaris, and gives attachment to the anterior annular ligament; if unsound, the bone must be removed entirely. In this operation, the extensors of the carpus are the only tendons necessarily divided; the flexor carpi radialis, escapes, being connected with the second metacarpal bone below its base, and the flexor carpi ulnaris is left attached to the pisiform bone. All the flexors and exten- sors of the fingers, and all the extensors of the thumb, should be unin- jured, and undisturbed beyond what is absolutely necessary for the operation of excision. On remoAring the tourniquet, any haemorrhage can be readily arrested by torsion or ligature. The radial incision is closed by sutures, and also the ulnar incision at its ends, leaving the middle portion open for the introduction of lint to allow free exit of the purulent discharge which necessarily ensues. The hand is placed on a suitable splint, extending up the forearm, and EXCISION OF THE WRIST. 665 secured by a bandage. The most convenient form is an ordinary wooden splint, with an obtuse-angled piece of thick cork, cemented to the palmar portion by means of fused gutta-percha, and Avith a bar of cork stuck on transversely to the under-surface of the splint so as to project at the side. Lister's splint, thus constructed (Fig. 267), possesses certain important advantages. The hand lies semiflexed, which is its natural position of repose ; the fingers are midway between flexion and extension, into Avhich it is necessary to bring them by daily passiAre movements; while a certain range of voluntary motion is also permitted, which the patient should be encouraged to exercise frequently during the day. Then again, this posi- tion is best adapted for allowing the extensors of the carpus to acquire Fig. 267. fresh attachments ; -and, the palm resting on the sloping surface of cork, the splint cannot slip upwards; nor downwards, secured by turns of the bandage around the transverse bar of cork. This appendage to the splint specially keeps the thumb in position ; it is thus allowed to fall below the level of the rest of the hand, so as to be most serviceable for opposition to the fingers; Avhile the tendency to adduction of the thumb towards the index finger is prevented by a thick pad of lint placed in the angle between the tAvo, under the turns of bandage around the transverse bar of cork. The palmar piece of cork should be hollowed out to receive the ball of the thumb. After-treatment.—Two principles must be kept in view, in order to obtain a successful result. Firstly, to procure firm anchylosis of the wrist, by retaining it in a fixed position during the process of consolida- tion—for a period averaging six or seven Aveeks. Secondly, at the same time, to maintain the flexibility of the fingers and thumb, daily; com- mencing flexion on the second day, whether inflammation has subsided or not. In executing these movements, each finger should be both flexed and extended to the full degree, Avhile the connected metacarpal bone is held quite steady, so as not to disturb the Avrist. Both these principles are provided for by the peculiar construction of the splint, and Professor Lister attaches more importance to their fulfilment, in the after-treatment, than to his method of operation. Pronation and supination, also, must not long be neglected; and as the new Avrist acquires firmness; flexion and extension, abduction and adduc- tion, should be occasionally encouraged. The period during which passive motion should be practised may be resolved into this rule—it must continue until the disposition to contract adhesions finally ceases—a few Aveeks or a few months. When the patient leaves his bed, and carries his arm in a sling, the weight of the hand Avill make it gradually droop to the ulnar side; a ten- dency Avhich is best counteracted by affixing two ledges of gutta-percha 666 SPECIAL PATHOLOGY AND SURGERY. to the ulnar side of the splint—one to support the border of the hand, and the other to prevent any lateral shifting of the splint. As the hand acquires strength, more free play for the fingers should be allowed, by cutting away the splint up to the knuckles, leaving only the palm sup- ported. Some support must be continued until the patient feels the wrist as strong without it as with it. Earlier disuse of this support would assuredly undo the work of previous management, and lead to an unsuccessful result. A year, or even tw^o, of such finishing-off support may be required to gain the most useful hand. Results.—Fifteen cases of Wrist-Excision are recorded by Mr. Lister, as having occurred in his own practice. Of these cases, 12 were suc- cessful ; recovery taking place, and with a hand more or less completely useful in its varied movements of the fingers and thumb, and with com- bined strength and flexibility of the wrist. In 1 case the result was doubtful at the time of the report—four months after operation. In the remaining 2 cases, death ensued, though not directly from the operation; one patient dying, at the end of seven weeks, from advanced phthisis and other complaints ; the other patient, after re-excision about six months subsequent to the original operation, lived yet two months longer, when death occurred from phlebitis and pyaemia. Secondary haemorrhage, or any other bad symptom immediately referable to the operation, occurred in not a single instance. Thus, then, Lister's elaborate method of operation has been singularly safe and successful. Other and simple methods of operation have hitherto rarely proved successful; the results having been, in the majority of the few instances recorded, either a stiff and useless hand, or recurrence of the disease and secondary amputation. Yet, it may fairly be doubted whether the superior results attained by Lister's method have not been due—as he himself acknowledges—more to the principles on which the q/for-treatment was conducted, than to the plan and performance of the operation. This conclusion seems to be established by two significant facts in the history of Mr. Lister's cases— that the period of recovery and the resulting condition of the hand were about equal in his earlier and later cases, while the method of operation was different. Author's Collection. (1) Royal Infirmary, Edinburgh ; period, 1865-69. (Per Mr. P. H. Watson.) Number of cases, 12 ; recoveries, 9 ; deaths, 3. (2) Liverpool Royal Infirmary; period, last five years. (Per Mr. W. J. Cleaver.) Number of cases, 6; recoveries, 6. (3) Chalmers Hospital, Edinburgh; period, last six years. (Per Mr. P. H. Watson.) Number of cases, 5 ; recoveries, 4; deaths, 1. (4) London Hospital; period, last five years. (Per Mr. J. McCarthy.) Number of cases, 3; recoveries, 2; deaths, 1; amputations after exci- sion, 1; recoveries, 1. (5) King's College Hospital; period, last five years. (Per the House-Surgeon.) Number of cases, 3 ; recoveries, 3. (6) St. Thomas's Hospital; period, 1866-70. (Per Mr. F. Churchill.) Number of cases, 1 ; recoveries, 1. (7) St. Bartholomew's Hospital; period, 1866-70. (Per Mr. Cal- lender.) Number of cases, 1 ; deaths, 1. EXCISION OF JOINTS FOR INJURY.—THE KNEE. 667 (8) Royal Free Hospital; period, last live years. Number of cases, 1 ; recoveries, 1. (9) Guy's Hospital; Westminster Hospital; Charing Cross Hospital; St. Mary's Hospital; Great Northern Hospital; Royal Albert Hospital, Devonport; Royal Sea-Bathing Infirmary, Margate; period, each last five years. No cases. The Hand may often be subjected very advantageously to various operations of Excision, both in regard to the Metacarpal Bones, and the Phalangeal Bones of the Fingers. The conditions of Disease appropriate for Excision, are precisely ana- logous with respect to any such operation on these bones of the hand, as in the corresponding bones of the foot. The articular ends, or the Avhole, of several, or of single bones, of the metacarpus or of the fingers, may thus be removed; instead of having recourse to amputation of portions of the hand, Avhich would unnecessarily include sound portions of this precious member. But the choice of either operation of removal, and the plan and performance of the procedure, must be determined by the kind and extent of disease, in each particular case. The general prin- ciple, here again, applies; Pathology is the guide as to the excisional operation, whereby also the portion of the hand Avhich may be preserved, is indicated. K.XCISION OF THE JOINTS FOR INJURY. Excision ok the Knee-joint, for Injury.—The operation of knee- joint excision, for injury to the joint, can only be appropriate in certain conditions, intermediate betAveen those which admit of cure without any operative interference, and those Avhich should be subjected to amputation of the thigh. Such injuries are more frequently too extensive, both in regard to the joints and surrounding soft parts, to admit even of excision; and must be submitted to amputation,—which operation, therefore, for injury, is an alternative procedure. But the constitutional condition will very probably be far more favourable in extensive injury, than in exten- sive disease,—the former occurring often to persons in high health, and not when the constitutional reserve-power, necessary for the long process of reparation after excision, has been reduced by long-continued pain or exhausted by discharge and hectic fever. Hence, this primary consideration with reference to the operation, as for disease, may probably be altogether omitted in selecting excision rather than amputation for injury to the joint. The question of operation arises more commonly in Military than in Civil practice. Conditions of Injury Appropriate for Excision. — (1) Lacerated Wounds of the Joint. Punctured Wound may alloAV of closure, and the treatment for consequent synovitis. In the event of inflammatory disease, thus of traumatic origin, having terminated in destruction of the arti- cular cartilages, Avithout the supervention of anchylosis; the propriety of excision must be determined by the same consideration as Avith refe- rence to idiopathic disease of the joint,—namely, the measure of con- stitutional reserve-power. (2) Compound Fracture involving the Joint. (3) Compound Dislocation of the Joint. (4) Gun-shot wouuds of the knee-joint may comprise one or more of these conditions, with perhaps the addition, as a complication, of a foreign body in, or near to, the joint. The operation is performed in accordance with the directions already 668 SPECIAL PATHOLOGY AND SURGERY. given, Avhen the joint is diseased; the incision being modified conform- ably to the state of the integument in injury of the joint. The after-treatment also is the same, as to the retentive appliances, and their reapplication from time to time, only as occasion may absolutely render necessary; but the more severe inflammation apt to arise after excision for injury, must be promptly met by more actively repressive measures. Results.—Cases of knee-joint excision for injury have been far less numerous than for disease ; and insufficient to establish any general con- clusions, as to mortality or secondary amputation. Cases of lacerated wound of the joint, for which the operation has been performed, have occurred; one in the practice of Mr. Kempe, of Exeter, the patient aged thirty, and the result perfectly successful, at the end of a year the patient being enabled to load a railway van; and in another case excision was resorted to by the late Mr. Price, as a secon- dary operation,—the patient six years old, having tAvo months previously sustained an extensive laceration of the knee-joint by a cart-wheel, folloAved by profuse suppuration and burrowing sinuses, yet apparently the result Avas successful. In a case of punctured wound of the knee joint, by a needle, re- sulting in anchylosis and dislocation; at the end of one year and four months, Sir William Fergusson excised the joint; the patient re- covering with a shortened but perfectly straight limb. In a similar case, under Mr. Erichsen, the patient recovered, with the natural cure by anchylosis. Cases of compound fracture of the knee-joint, for Avhich excision was practised have occurred; Dr. Watson having performed the operation in a case of compound, comminuted fracture of the patella, the fragments being impacted in the end of the femur, and the result of its excision, fatal: Mr. Crompton, in a case of compound fracture of the condyle of the femur, had a successful result to the operation ; and, in a case of forcible separation of the lower epiphysis from the shaft of the femur, the patient being aged fifteen, sloughing ensued and protrusion of the end of the femur, for which Mr. Canton excised the joint, and with a perfectly successful result. In a similar case, the same Surgeon having performed excision, re-excision of a further protrusion of the femur was practised; and fibrous anchylosis with a useless limb resulting, Mr. Canton amputated the thigh, and the patient recovered. Compound dislocation of the knee-joint will rarely admit of excision; owing to the extent of disorganization, amputation may be imperative. Gunshot injury to the knee-joint, has not unfrequently allowed of excision, but the results have been far more frequently successful in Civil, than in Military practice. Successful cases have occurred; one at the London Hospital, under the care of Mr. J. Hutchinson; another, at the General Hospital, Birmingham, under Mr. Crompton; and M. Spillmann has collected the history of 13 cases of knee-joint excision in Civil prac- tice, for gunshot injury, with only 3 deaths. On the other hand, under, probably, the less favourable circumstances of Military practice, the ope- ration has been deadly. Of 21 such cases, collected by M. Spillmann, 19 Avere fatal. During the Crimean War, the returns of excision show only 1 case of excision of the knee-joint, and with a fatal issue. In the American War, the report from the Surgeon-General's department, records in a tabulated form, 770 terminated cases of gunshot Avounds of EXCISION OF THE HIP-JOINT, FOR INJURY. 669 the knee-joint; in 11 cases of excision, only 2 recovered, or a mortality of 90 per cent.; Avhilst the mortality from amputation was far loAver,— 73-43 per cent., still a very melancholy record. Free incisions into the joint seem to have succeeded little better than excision. The results of the operation, as collected by M. Peniere, are very impressive. In Civil practice, of 7 cases ; there Avere 4 recoveries, and 3 deaths, or 1 in 2J; whereas, in Military practice, of 20 cases, 3 only recovered, and 17 died, —an overwhelming mortality. All these cases are taken almost exclu- sively from foreign sources. It Avould appear, therefore, that while ex- cision of the knee-joint for injury, may be less successful than the average 'minimum success of the operation for disease: the mortality in Military practice is so excessive, as to suggest the propriety of there abandoning the operation in favour of amputation of the thigh. Author's Collection. (1) Great Northern Hospital; period, last five years. (Per Mr. J. Willis.) Number of cases, 2 ; recoA-eries, 2. (2) St. Thomas's Hospital; period, 1866-70. (Per Mr. F. Churchill.) Number of cases, 1 ; deaths, 1. (3) Royal Free Hospital; period, last five years. Number of cases, 1 ; recoveries, 1. (4) Royal Infirmary, Edinburgh ; period, last five years. (Per Mr. P. H. Watson.) Number of cases, 1; deaths, 1. (5) Chalmers Hospital, Edinburgh; period, last six years. (Per Mr. P. H. Watson.) Number of cases, 1 ; deaths, 1. (6) Guy's Hospital ; St. Bartholomew's Hospital ; London Hospital ; Westminster Hospital; St. Mary's Hospital; Charing Cross Hospital; King's College Hospital ; Liverpool Royal Infirmary ; Royal Albert Hospital, Devonport; Royal Sea-Bathing Infirmary, Margate ; period, each last five years. No cases. Excision of the Hip-joint, for Injury.—This operation, like that for the knee-joint on account of injury, relates more to Military than to Civil Practice. It Avas first performed, as reported by Oppenheim, at the battle of Eski-Arna-Utlar, between the Russians and Turks, on the 5th May, 1829. The injury Avas that of a gunshot wound of the hip, Avith fracture of the head and neck of the femur and of the upper edge of the cotyloid cavity; the soft parts being little injured, and the nerves and large vessels untouched. Death took place after the seventeenth day, apparently, however, from fright. The operation Avas adArocated by Guthrie; and practised during the Crimean War, both in the English and French Hospitals. Conditions of Injury appropriate for Excision. — (1) Compound Fracture of the upper part of the femur, and perhaps involving the acetabulum. (2) Compound Dislocation of the Hip-joint—a rare form of injury. (3) Gunshot Wound of the Hip-joint; comprising either of these conditions, and more often fracture. The diagnosis, as to the kind and extent of injury may be very difficult. Possibly, no shortening, eversion, or crepitus, and little loss of poAver to move the limb in flexion or exten- sion ; only a small aperture to be seen in the thigh, before or behind, Avith no haemorrhage, and no pain experienced by the patient. ( I) Wrench of the hip-joint, a form of injury described by Brodie, has also been suggested as an appropriate condition for excision. But, 670 SPECIAL PATHOLOGY AND SURGERY. the impossibility of an accurate diagnosis in this case, Avould forbid so serious an operation. The operation of excision for injury is performed in the same way as for disease, modified only by the state of the integument. Aftei--treat- ment also requires no special notice. Results.—In the Crimea; of the 14 cases of this operation in the English Hospitals, only 1 recovered; of the 13 cases in the French Hos- pitals, all were fatal; and in the Schleswig-Holstein campaign, of the 7 cases there was only 1 recovery. The successful Crimean case had been operated on by Dr. O'Leary. A fragment of shell struck the great trochanter of the left femur, pro- ducing a fracture, which commenced close to the head of the bone, and extended doAATiwards and forwards between the two trochanters, termi- nating about an inch and a quarter below the lesser. The external wound was small. The head of the femur and the trochanters were removed. In three months the man left his bed on crutches. At the end of six months, he had gradually regained the use of his limb, and, some time afterwards, was seen in London, in excellent health. Although an almost invariably fatal operation, the duration of life after excision shows that it has no immediate danger. In the cases re- corded ; one of the patients lived 5 weeks, others from 6 to 17 days, and only 1 for so short a period as 22 hours. On the other hand, natural recovery is almost hopeless. From gun- shot wound of the hip-joint, one such result occurred after the battle of Solferino; and another was seen at Nantes, in 1830, by M. Boinet. Compared with Amputation at the hip-joint; in Military practice, re- covery very rarely ensues, death taking place usually within a day or two after this operation. In the dilemma from the almost certain mortality of trusting to Nature, or performing amputation ; the Surgeon may perhaps judiciously have recourse to the chance afforded by excision. In the 15 Hospitals stated in previous Tables, respecting Joint- Excisions during the last five years; it appears, from the Returns with which I have been favoured, that there has been no case of excision of the Hip-joint, for Injury. Excision of the Ankle-joint, for Injury.—This operation is referred to by Faure, as having been performed in a case which occurred at the Battle of Fontenoy ; a wound of the ankle-joint by a " bisca'ien." The articular ends of the tibia and fibula, with the astragalus and portions of the other tarsal bones, were excised ; but amputation was performed on the 47th day. Subsequently, excision of the articular ends of bone Avas performed by Mr. Cooper, of Bungay, for compound dislocation; the case being referred to in 1758, by Mr. Benjamin Gooch of Norwich. Cases, in which to the extent of tAvo, three, and even four inches, the ends of the tibia and fibula were removed for injury, are related by Bilguer in 1781. Moreau, in 1792, performed this operation, with success, for com- pound dislocation, 19 days after the accident. In 1805, Park alludes to a case of excision of the tibial end for similar injury to the ankle; and, according to Mr. Hey of Leeds, in the same year, Mr. Taylor of Wake- field, had performed this operation in 5 cases. Sir Astley Cooper, Liston and Malgaigne, have advocated removal of the ends of the tibia and fibula, in cases of compound dislocation, as being preferable to reduction or amputation. Mr. Jones of Jersey, performed complete excision—the EXCISION OF THE SHOULDER-JOINT, FOR INJURY. 671 articular ends of bone and the surface of the astragalus, as a secondary operation ; 22 days after compound dislocation Avith fracture of the mal- leoli, folloAved by necrosis, profuse suppuration, and constitutional dis- turbance. In about 3 months, the patient, having for ten days previously been able to walk some distance without support, ran away from the Hospital, and Avalked a distance of five miles with the aid of a stick and a crutch. A similar operation for a similar condition of the parts, Avas performed 5 months after the injury, by C. W. Klose, in 1854. The patient, 60 years of age, at the end of 10 weeks was able to Avalk out Avith a crutch. Conditions of Injury appropriate for Excision.—(1) Compound fracture of the malleoli, Avith perhaps contusion of the bone. (2) Compound dislocation of the ankle-joint. In either of these conditions, it is presumed, that the ends of bone cannot be reduced, or if reduced, kept in position ; and that the integu- ments are not so much lacerated or contused as to slough ; unaccom- panied also with comminution of the other tarsal bones. The operation, and after-treatment, require no special notice. Results.—In 29 cases, reported in Jaeger's tables, only 1 death oc- curred. Malgaigne records the unexceptional success of 5 operations by Taylor, 6 by Josse, and 9 by Sir A. Cooper. Compared icith amputation of the leg, for injury, the balance is highly favourable to excision. At Guy's Hospital, the mortality has been 62-5 per cent, in primary, and 66'66 per cent, in secondary amputations; while in the Royal Infirmary of Edinburgh, Mr. Syme records a mortality of 11, or 65 per cent., out of 13 amputations for compound dislocation of the tibia and fibula. . As to the state of the foot, after excision, the resulting condition has usually been anchylosis; but in some cases, reported by Sir A. Cooper, motion was preserved. Author's Collection. (1) London Hospital. Number of cases, 2; recoveries, 2; secon- dary amputation, 1 ; deaths, 1. (2) Royal Infirmary, Edinburgh. Number of cases, 2 ; recoveries, 1 ; deaths, 1. (3) Liverpool Royal Infirmary. Number of cases, 2 ; recoveries, 2; secondary amputations, 1 ; recoveries, 1. (4) Guy's Hospital; St. Bartholomew's Hospital; St. Thomas's Hospital ; King's College Hospital; Charing Cross Hospital; St. Mary's Hospital; AYestminster Hospital; Royal Free Hospital; Great Northern Hospital; Royal Albert Hospital, Devonport ; Royal Sea-Bathing Infir- marv, Margate ; Chalmers Hospital, Edinburgh. No cases. in each of these Hospitals, the Period is that of the last five years ; and the Returns Avere made to me by those Surgeons whose names are severally affixed in the previous Tables. Excision of the Shoulder-joint, for Injury.—The contingencies of Avarfare render this operation far more common in Military than in Civil practice. It Avould appear from the French official report in the Crimea; that in open engagements, the superior extremity Avas Avounded once in every 4"3, and in siege operations, once in every 62, of all wounds re- ported. Of -17 gunshot wounds of the upper extremity, 28 Avere of the shoulder and arm. The advanced position of the soldier's shoulder, 672 SPECIAL PATHOLOGY AND SURGERY. in the act of firing, exposes that part more particularly to bullet-Avounds; while it also shares the liability of other parts to grape-shot, fragments of shell, and cannon-balls. M. Boucher of Lille, seems to have first performed the operation of shoulder-joint excision, after the Battle of Fontenoy, in May, 1745. Subsequently complete excisions were practised successfully by Percy, Sabatier, Larrey, Lauer, Ingalls of Boston, Mann, Guthrie, Baudens, Hancock, and other Surgeons. Conditions of Injury appropriate for Excision.—(1) Compound and comminuted fracture of the head and neck of the humerus. (2) Compound dislocation. (3) Gunshot wound, involving the head or neck of the humerus; extending down the shaft even into the medullary canal. Such fissures may be left, and recovery ensue; or, the shaft to the extent of four or five inches has been removed, Avith the head, and a successful result ensue. Complications, by fracture of the glenoid cavity of the scapula, through the neck, or extending into the body, or involving the coracoid and acromion processes, may require the removal of such additional fragments, or they may be left to exfoliate; the result proving successful, although recovery be protracted. Thus, Larrey's case Avas remarkable for the extent of bone excised,—head of humerus, acromion, and proxi- mate end of the clavicle; yet the patient recovered, and with consider- able use of the arm. Partial excision of the head of the humerus was practised in the Crimea. The after-mobility Avas more restricted, than as the result of complete excision. A bullet imbedded in the head of the humerus may not unfrequently be extracted, without excision. The state of the integuments, and of injury to the axillary vessels and nerves, will regulate the propriety of excision. The operation is performed as for disease, modified only by the state of the integuments. The shape of the incision will be chiefly directed by the situation of the wound or wounds in the skin. A shattered shoulder from gunshot Avound necessitates a sort of trimming-up excision ; by enlarging the Avound, and extracting splinters of bone. A perpendicular linear incision, from the acromion process dowmvards through the middle of the deltoid muscle, will probably suffice to expose the crushed head of the humerus. Removal of the disintegrated and splintered fragments must then be performed secundum artem. After-treatment must be conducted on the same principle. Results.—In 53 primary excisions of the shoulder-joint for injury, the mortality was 16. In 34 secondary operations, there were 6 deaths. Combining these two series of cases, and adding thereto, 6 operations with 3 deaths, by Baudens, and 3 others, successful,—1 by Langenbeck, and 2 by Textor, of which it is unknown whether they were primary or secondary; the total number is 96 cases, Avith 25 deaths, or a mor- tality of 26 per cent. Secondary excision has a comparatively more favourable mortality than the primary operation. Thus, in the 53 primary excisions, the percentage Avas 30-18; whereas, in the 34 secondary operations, the per- centage was only 17-64,—a balance of 12-54 in favour of the latter. More striking are the results reported by Esmarch. Of 6 excisions of EXCISION OF THE ELBOW-JOINT, FOR INJURY. 673 the head of the humerus, performed within twenty-four hours after the inJurv> 2 died; of three during the inflammatory stage, or on the third or fourth day, 2 died; whereas of 10 after suppuration was established, only the same proportion, 2, died. Of 26 patients in the ambulances of M. Baudens; 11 immediate excisions made 10 recoveries, 3 were sub- mitted to secondary excision, and all were successful. In the Crimean returns, also, the cases were equally successful. The period of recovery after shoulder-joint excision for injury, seems to be about tAvo or three months in respect to treatment, the complete result as to usefulness of the arm not being obtained under twelve months, or a longer period. In the Crimea, the Schleswig-Holstein campaign, and the last Indian mutiny, many of the soldiers who had been thus operated on, returned to their regiments or to a modified duty, before the end of the war. Compared with natural cure, excision has proved most favourable. Thus, of 8 cases suited for excision, but which were left to nature, 5 died, and the remaining 3, at the end of six months, were uncured. Of M. Baudens' cases, 15 were left to nature; 8 of these died from purulent infection, and 4 suffered long from fistulous openings,—the remaining 3 having undergone secondary excision. Compared with amputation at the shoulder-joint, the results of ex- cision are also favourable. In the Crimea, of 60 such amputations, 19 were fatal, or a percentage of 31'6; leaving in favour of excision, a balance of 5*6 per cent. A curious comparison has been drawn between the results of excision on the right and left shoulder-joints. According to Esmarch, operation on the right side is more successful than on the left side; of the latter cases, 6 out of 12 having died, but only 1 out of 7 of right-shoulder excisions. Author's Collection. (1) Royal Infirmary, Edinburgh. Number of cases, 1; recoveries, 1. (2) Royal Infirmary, Liverpool. Number of cases, 1; recoveries, 1. (3) St. BartholomeAv's Hospital; St. Thomas's Hospital; Guy's Hospital; St. Mary's Hospital; King's College Hospital; London Hos- pital ; Westminster Hospital; Charing Cross Hospital; Royal Free Hospital; Great Northern Hospital; Royal Albert Hospital, Devonport; Royal Sea-Bathing Infirmary, Margate; Chalmers Hospital, Edinburgh. No cases. In each of these Hospitals, the Period is that of the last five years; and the Returns were made to me by those Surgeons whose names are severally affixed in the previous Tables. Excision of the Elboav-joint, for Injury.—This operation appears to have been first performed by Wainman, of Shripton, in 1758 or 1759 ; the case having been one of compound dislocation, the articular end of the humerus Avas removed just above the olecranon fossa, the patient recovered, and Avith a flexible arm, "as if nothing had ever been amiss." This operation is famous in the history of Excisional Surgery of the Joints, on account of its very early date. Subsequently, Tyre of Glou- cester, excised tAvo inches and a half of the lower end of the humerus, for a compound dislocation. Larrey urged this excision upon his Sur- geons, but according to Percy, without much effect; " timidity, care- lessness, routine, and indifference (words to be remembered) too often x x 674 SPECIAL PATHOLOGY AND SURGERY. led them to prefer amputation, even under the very eyes of the old chieftain of Military Surgery." In 1840, Mr. Alcock could find no in- stance of the complete excision of the elbow-joint, in the annals of either British or French Military Surgery. It was not until the Schleswig- Holstein War of 1848-51, that this operation was really introduced into Military practice, by B. Langenbeck of Berlin, and L. Stromeyer of Erlangen. Excision of the elbow-joint for injury is, indeed, more often required in Avarfare than in civil practice; though the nature of the injuries, and the circumstances of the patient after operation, may, as with regard to other joints, render the prospect of recovery less favour- able in the one case than in the other. Conditions of Injury Appropriate for Excision.—(1) Compound and comminuted fracture of the elbow-joint. (2) Compound dislocation. (3) Gunshot-wound, involving the joint. Fissures of the humerus, just above the joint, more commonly extend downward than upward. The track of a ball near the joint often induces caries, which would ultimately require excision. But the state of the integument, and of the brachial artery and the nerves, at the bend of the elbow, will regulate the propriety of excision instead of amputation. The operation, and a/for-treatment, are analogous to that for disease. Results.—In 12 cases of severe injury to the elbow-joint, reported by Mr. Jonathan Hutchinson, the results were decidedly in favour of excision, rather than of either natural cure, or primary amputation. An elbow-joint apparently preserved by the reduction of compound fracture or dislocation, is apt to entail profuse suppuration and constitutional dis- turbance, perhaps necessitating amputation of the arm; or the motion and consequent use of the arm eventually is less than after excision of the ends of bone. Both these conclusions are established by Mr. Hutchinson's cases; and the latter, as to the use of the arm, is confirmed by Macleod's report of the Surgery in the Crimean War. In Civil Hospitals, the success of operation is very remarkable ; of 21 cases, authenticated by Dr. R. Hodges, in his excellent treatise on Joint- Excisions, a rapid recovery ensued in all but one, the fatal result of which was in no way attributable to the operation. Compared with Amputation, the mortality of excision contrasts very favourably. Of 13 amputations of the upper extremity, in Guy's Hos- pital, on account of injury, 1 in 4-33, or 33 per cent., of primary, and 1 in 5, or 20 per cent., of secondary operations, proved fatal. In Military Hospitals, the results have been less successful, but still in favour of excision. Combining the experience of the Grimean War, and of the Schleswig-Holstein campaign, we have a total number of cases in proof of this position. Of 60 excisions, 11 Avere fatal, or a mortality of 18-33 per cent. Whereas, of 208 amputations, 48 were fatal, or a mor- tality of 23'07 per cent. Thence, a percentage of 4'74 in favour of exci- sion. Partial excisions have not been so successful as the complete opera- tion. This was shown in civil practice, by the results of 7 of the 21 cases referred to, where the partial operation was performed; 3 made good results, 1 ended in partial anchylosis, in 1 extension was imperfect, in 1, failure was imputed to habits of intemperance, and of 1 the result is wanting. Military practice, as taught by the results of the Crimean War, points to the same conclusion. Partial excisions of the elbow were more tedious in recovery, more liable to fail, and the results, when successful, Avere less perfect. EXCISION OF THE WRIST, FOR INJURY. 675 Secondary excision, at the period of suppuration, say at the end of a Aveek, if it be not preferable to the primary operation, would seem not to be unfavourable to recovery. This is the opinion of Stromeyer, and U is confirmed by Esmarch's statistics—that of 11 excisions within the first tAventy-four hours of the injury, 1 died ; of 20 performed during the inflammatory stage—from the second to the fourth day, 4 died; of 9 secondary excisions in the period from the eighth to the thirty-seventh day, only 1 died. The right elbow-joint, like the right shoulder, would appear to be more favourable for excision, in regard to recovery. On the right side, only 2 in 20 operations proved fatal; whereas, on the left side, 4 in 19 were fatal—a more than double mortality. Indeed, comparing the total results of the shoulder and elbow-joint excisions, the mortality on the left arm to that on the right is as 3 to 1. Author's Collection. (1) Royal Infirmary Liverpool. Number of cases, 8; recoveries, 8. (2) London Hospital. Number of cases, 6 ; recoveries, 5; deaths, 1. (3) Royal Free Hospital. Number of cases, 2 ; recoveries, 2. (4) Royal Infirmary, Edinburgh. Number of cases, 2 ; recoveries, 2 ; secondary amputations, 1 ; deaths, 1. (5) Great Northern Hospital. Number of cases, 1; recoveries, 1. (6) St. Thomas's Hospital"; Guy's Hospital; St. Bartholomew's Hospital ; Westminster Hospital: St. Mary's Hospital; Charing Cross Hospital; King's College Hospital; Royal Albert Hospital, Devonport; Royal Sea-Bathing Infirmary, Margate ; Chalmers Hospital, Edinburgh. In each of these Hospitals, the Period is that of the last five years ; and the Returns were made to me by those Surgeons Avhose names are seve- rally affixed in the previous Tables. Excision of the Wrist, for Injury.—A partial excision of the •wrist-joint—the radio-carpal articulation, appears to have been first per- formed, for injury, by Cooper of Bungay. " He sawed off the head of the radius, A\rhich passed through and made a dismal laceration of the tendons at the wrist, and the patient found little or no defect in the strength or motion of the joint." Thus reported by Benjamin Gooch, in 1758, this operation Avas practised also by that Surgeon, who succeeded beyond his expectation in cases of a similar nature. At about the same period, M. Bagieu removed the comminuted bones of the wrist-joint, crushed by gun-shot injury ; anchylosis ensued, and the fingers were left so flexible, that the patient, a soldier, aged twenty-five, was able to Avrite and draw, and retained to a very considerable extent, the shape of the hand. About the year 1773, Bilguer excised some two or three inches of the wrist-end of the ulna, in a case of injury. In 1800, M. St. Hilaire of Montpellier, removed the ends of both radius and ulna, for compound dislocation, and Avith perfect success. In 1828, M. Hublier of Provins, performed the same operation, for similar injury accompanied with rup- ture of the tendons; and Huguier and Rossi repeated it for gunshot wounds of the wrist. Subsequently, excision Avas performed in the Crimea. Conditions of fnjury Appropriate for Excision.—The comparatively few cases recorded Avith regard to excision for injury, are insufficient to establish any general conclusions. But, so far as experience has extended, and the analogy suggested by other joints, the following forms of injury to the wrist Avould seem to be proper for some such operation. xx 2 676 SPECIAL PATHOLOGY AND SURGERY. (1) Compound and comminuted fracture. (2) Compound dislocation. (3) Gunshot wound, comprising either or both these conditions. The complication of injury to the tendons at the wrist, does not forbid the operation; but the state of the adjacent vessels and nerves may be more important. Preservation of the hand, even in the most imperfect result for use, is so great a gain over the entire loss of this member, that the chance offered by excision -will generally be preferable to primary amputation, at the wrist or in the forearm. The operation and a/ter-treatrnent, must be conducted on the prin- ciples laid down as for disease, modified only by the circumstances of the injury. Results.—Some of the earlier cases have already been noticed. In the Crimea 3 cases of wrist-injury were submitted to excision, with 1 fatal result. Partial excision, for compound dislocation of one or more of the carpal bones, has been practised occasionally, and with some success. Thus, Sir A. Cooper removed the scaphoid, and Malgaigne, the semi-lunar bone. Author's Collection. (1) London Hospital. Number of cases, 1; recoveries, 1; secondary amputations, 1; recoveries, 1. (2) Royal Infirmary, Edinburgh. Number of cases, 1; deaths, 1. (3) St. Thomas's Hospital; Guy's Hospital; St. Bartholomew's Hospital; King's College Hospital; St. Mary's Hospital; Westminster Hospital; Charing Cross Hospital; Royal Free Hospital; Great Northern Hospital; Liverpool Royal Infirmary ; Royal Albert Hospital, Devon- port ; Royal Sea-Bathing Infirmary, Margate; Chalmers Hospital, Edinburgh. No cases. In each of these Hospitals, the Period is that of the last five years; and the Returns were made to me by those Surgeons Avhose names are severally affixed in the previous Tables. Excision of Bones. Excision of Upper Jaav and Lower Jaw.—See Diseases of the Jaws, Ch. XLIV. Excision of the Scapula.—Complete Excision of this bone was originally performed by Cumming in 1808 ; afterwards by Gaetani Bey, 1830 ; and by Larrey, 1838 ; each of whom amputated the arm, and then excised the scapula; and more recently by Syme, Jones of Jersey, Cock, Fergusson, and Pollock, all of whom disarticulated at the shoulder- joint, leaving the arm untouched. The scapula, with the clavicle, have been removed by American Surgeons ; by Massey, 1837 ; by McClellan, 1838; and both these bones, or rather the outer half of the clavicle, with the upper extremity, have been removed by Gilbert, in two cases; and by Massey, 1845. Partial excision of the scapula has been practised by Liston, 1819; Luke, 1828; and by Hayman, Janson, Wiitzer, Textor, Gross, and the Author. In these operations, the glenoid cavity was always left,—the only portion in Gross's case. The conditions of disease for which excision of the scapula may be required, in whole, or in part; are caries or necrosis, and tumour. The results of operation have been successful in the majority of cases, EXCISION OF THE SCAPULA. 677 unless from the recurrence of the disease, and the arm has become very useful. Even the formidable operations of excision including the clavicle, and with amputation of the upper extremity, have proved successful. Operation.—Partial excision of the scapula, for caries or a tumour, will require an incision, varying in shape and extent, according to the portion of bone, or the size and relative position of the tumour, to be removed; thus, the body of the scapula may be excised by a T-snaPe